Royal college condemns obesity surgery stand-off

Clinical commissioning groups and local authorities are in conflict with NHS England, leading to confusion which has hampered the treatment of patients needing procedures like stomach stapling or gastric band fitting.

As HSJ reported in October, the national service criteria set by NHS England for the treatment state that a patient must have received “tier 3” intensive weight management support in advance.

These non-surgical measures can include psychological assessments to ensure patients are doing everything possible to lose weight before resorting to surgery. Although CCGs commission some of these services, in some areas this role is performed by councils, following the transfer of responsibility for public health to local authorities.

Some CCGs and local authorities target their support at people who have not yet reached the highest levels of obesity and therefore do not commission tier 3 services.

Norman Williams, president of the Royal College of Surgeons, said: “To hear that a postcode lottery is emerging in UK weight management provision is deeply worrying.”

In an interview with HSJ, NHS England national clinical director of specialised services James Palmer would not confirm which areas offered no tier three services.

He added that tier 3 services were easy and inexpensive to set up.

On Monday NHS England said it had set up a working group made up of CCGs, local authorities, the Department of Health, Public Health England and the National Institute for Health and Care Excellence to tackle the problem, and it would issue recommendations “shortly”.

A request from providers in October to allow surgery without tier 3 services was rejected by Dr Palmer who said it could “put patients at unnecessary risk”.

Dr Palmer told HSJ that before the national specification for bariatric surgery was drawn up that the pathway was “broken” and there had been 28 different policies across England.

From April, NHS England will not pay providers for work that does not meet the new specification.

Dr Palmer said it “would be scandalous if [patients] could just go straight to the most risky, most expensive procedures” without having weight management services beforehand.

He also confirmed that the “derogation” process, which sees any provider with services that do not meet NHS England’s specifications given a deadline to comply, would result in some reconfigurations of services.

In the interview which took place last month, Dr Palmer told HSJ that while most of the derogations in place across the country would be removed when providers completed work plans to satisfy the requirements, in a small number of providers this would not be possible. He said the number of areas where reconfiguration was required would be in “single figures”.

This could see some providers told they have to stop offering services by the end of January.

He described the conversations with providers as being “really difficult” and said most service reconfigurations were likely to involve burns and vascular services.

There are 619 agreed derogations with providers at the moment.

He said the systematic specification of services had never been attempted “at this scale” before in the English NHS.