Obesity is perhaps the biggest crisis facing the nation’s health. Effective treatments such as bariatric surgery must be used more widely, say David Haslam and Carel Le Roux.
The rise in obesity is unrelenting. The UK is now the fifth fattest nation in the developed world, with one in four people classified as clinically obese. Of all the crises facing the nation’s health and the NHS, obesity is perhaps the greatest.
The failure by the NHS to provide surgical treatment for severe and complex obesity is costing the wider economy hundreds of millions of pounds a year from excess costs of disability, social care and inability to work. The Shedding the Pounds report published by the Office of Health Economics emphasised that, based on clinical and economic grounds, healthcare professionals now have no choice but to respond.
£4.2bn:
Current NHS spending on the consequences of obesity
Effective and long term treatment options for severe and complex obesity, such as weight loss surgery, are being greatly underused. Even though the NHS spends approximately £4.2bn on the consequences of obesity, 97 per cent of eligible patients do not have access to such treatment,
The indirect healthcare and social costs of the obesity epidemic are estimated at around £16bn and are predicted to more than double by 2050.
However, as the report highlights, the health economic outcomes of bariatric surgery are not only positive, but are also significantly better than non-surgical management and are sustained over at least 15 years. In fact, the research found bariatric surgery can be cost-neutral after just three years and can benefit the economy to the tune of £191m per year through NHS savings and the contribution of paid work.
Barrier to treatment
Yet cost is often cited as a major barrier for NHS managers and other interested parties. At around £3,000-£6,500 per procedure, NHS commissioners are reluctant to fund what they may regard as “new and unproven procedures”. The irony in this barrier to surgical treatment is that those same budget holders who have concerns about the cost of surgery frequently insist on, and pay for, a variable course of non-surgical approaches to weight loss, even though these have never been shown to deliver a lasting health benefit.
In terms of comorbidities, the risks associated with developing obesity related conditions such as type 2 diabetes, hypertension and heart disease increase exponentially. The Department of Health estimates that around 58 per cent of type 2 diabetes, 21 per cent of heart disease and up to 42 per cent of certain cancer cases (endometrial, breast, and colon) are attributable to excess body weight.
However, non-surgical treatments have so far struggled to demonstrate sufficient levels of prolonged weight loss to affect these associated conditions.
How it works
Bariatric surgery procedures include gastric banding (pictured), in which a ring is placed around the top portion of the stomach to create a small pouch above. When the patient eats, the pouch fills up quickly and a full message is sent to the brain. The band also slows the release of food to the rest of the stomach and intestines, increasing the period of time the patient feels full.
Bariatric surgery has the capacity to induce major weight loss in the long term and also leads to the remission of diabetes in around 78 per cent of cases. It is estimated that the NHS spends around £9bn on diabetes. The cost attributed to dealing with a patient who has suffered a severe hypo (including paramedic costs) is approximately £1,000.
Bariatric surgery also has profound effects on patients suffering from sleep apnoea syndrome – thought to account for 300 deaths on the road each year where patients fall asleep at the wheel. Furthermore, over a seven year period, cancer death rate is reduced by 60 per cent in patients who have had surgery compared with those who did not.
It is necessary to determine which patients are the most expensive for the primary care trusts and clinical commissioning groups – those for whom cost grounds are not an acceptable reason for not being put forward for bariatric surgery.
58%:
Proportion of type 2 diabetes cases attributable to body weight
Current statistics and information suggests the direct healthcare costs from obesity associated diseases such as type 2 diabetes, obstructive sleep apnoea, infertility and cardiovascular disease are projected to rise to £6.3bn by 2015. There is a huge potential benefit from treating patients within these four groups.
International perspective
In other countries, such as the US, weight loss surgery has been more cost-effective long term for healthcare systems due to the resultant reduction in chronic obesity related illnesses. This is mainly because these health problems take a huge amount of the healthcare budget: patients need to see the GP regularly; have various treatments for the associated chronic illnesses such as laser therapy for their eyes, kidney treatment and dialysis, heart bypasses and nursing care.
Most of these could potentially be prevented if the NHS intervened early with surgery, making it much more cost-effective for healthcare budget holders in contrast to the use of expensive new medications.
Tackling such numbers needs bold action which requires severe and complex obesity to be treated as a priority. This is not simply a health issue. Patients need continued support to improve their health and to maintain the benefits. The challenge has been set and the urgency to meet it is growing.
Given the well documented costs associated with type 2 diabetes, sleep apnoea, infertility and cardiovascular disease, treating these patients with a BMI of over 35 with bariatric surgery will be cost effective.
PCTs and clinical commissioning groups need to aid clinicians in order to provide the necessary support required to face this challenge head on, enhancing the ability to refer patients for the most effective and cost-effective treatments available. Long term treatment options to the obesity problem are well known, can make a difference and should be available for suitable patients.
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