Select Committee on Health Minutes of Evidence

Memorandum by Professor John Baxter (OB 109)

  For the past five years I have been a serving officer of the British Obesity Surgery Society (BOSS). BOSS represents British surgeons who have an interest in treating extreme obesity (morbid obesity ie BMI>40) by surgical means. In the UK around 0.8% of males and 2% of females are morbidly obese. This represents around 228,000 males and 570,000 females who are potentially suitable for surgery. Furthermore if we take all patients who have a BMI between 35 and 40 who have a co-morbid condition this would push the target population up to 1.2 million. Furthermore, it is also predicted that 5000-8000 patients each year will also become morbidly obese. If only 5% of suitable patients opt for surgery (a very conservative estimate) this would mean that there are around 60,000 patients who need surgery right now—a "backlog". In the UK we manage to perform about 200-300 procedures per year. In Sweden it is thought that to maintain a steady state you need to perform about 500-1000 operations annually per 500,000 population. NICE, who recently gave their overwhelming approval for obesity surgery, have suggested that we should aim to perform around 4000 procedures per year (after eight years), a number which is manifestly too low. Using Swedish data and making some assumptions we would need to carry out a minimum of around 25,000 procedures per year! The potential cost savings for the NHS of not doing this is a missed opportunity.

  The reasons for the poor performance of the NHS in this area are the result of:

    —  Lack of trained obesity surgeons

    —  Lack of NHS capacity—especially lack of extra funding for obesity surgery (much of this surgery is done in private hospitals)

    —  Lack of a decisive approach to management of obesity in general—in particular lack of a regional plan for obesity surgery

    —  Prejudice by commissioners and health-care staff—in particular lack of pressure on PCTs to fund this surgery in trusts

  The BOSS has undertaken to establish training courses for obesity surgeons and also to give advice on the minimum standards and requirements for an obesity surgical service. Ideally, an obesity surgical service should be provided for a population of around 500,000 as part of the upper gastro-intestinal service offered by the hospital services. At present in the UK we have around 13-15 accredited obesity surgeons when according to the calculations above we would need several hundred obesity surgeons to deliver a comprehensive service. A postcode service is currently available with many areas of the UK without any service at all.

  The UK is well behind other European countries with respect to its development of obesity surgical services—a situation which unfortunately pertains in many areas of the NHS. In order to correct this situation there needs to be a much greater imperative given to the management of obesity in general including the use of the surgery. Members of BOSS are willing to help wherever possible to improve the current situation. We see the real problem as a lack of decisive leadership in the DoH with respect to addressing the implementation of the NICE report on surgery for obesity. It cannot be done in a cost neutral way which appears to be the flawed approach that is currently being pursued to implement NICE guidelines. New solutions have to be found which involve consideration of the following:

    —  Setting up of regional bariatric surgery units in the NHS

    —  Commissioning by the NHS of more bariatric surgery in the well-established private obesity surgery hospitals

    —  Identification of funding for obesity surgery development (training, equipment, staff, etc)

    —  Giving obesity in general a much higher profile as a healthcare problem


  There are many procedures which can be performed on the stomach to reduce weight in morbid obesity. Most of these can now be done laparoscopically ("key hole surgery") which reduces the time in hospital and accelerates patient recovery. The commonest procedures are gastric banding and gastric bypass. Selection for surgery is usually part of a multidisciplinary team approach. The patient must be morbidly obese (or BMI>35 with at least one comorbid condition which would respond to weight loss), have had morbid obesity for at least five years, have failed conservative treatment, not be an alcoholic, be a reasonable operative risk and be aged between 18-55.

  After the operation all patients should be followed up indefinitely although it is possible to discharge them back to their primary care doctor after two years. They need to have available dietician advice and preferably some form of patient support group. All operations will usually result in the patient losing at 50% of their excess weight and in many cases up to 65-70% of excess weight will be lost. The average operative mortality is 1% but usually it is much lower than this. There is excellent evidence (see NICE guidance) that co-morbidities are reduced after surgery, especially improvement in diabetes, reduced blood lipid levels, reduced incidence of atheroma affecting the arteries, improved cardiac and respiratory function, improved mobility, improved quality of life, higher rates of employment and reduced cost to the health service.

  Around 95% of morbidly obese patients fail to lose and maintain sufficient weight loss by conservative means. Obesity surgery is the only effective treatment available for these patients and it is being denied to them by resource constraints in the NHS.

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Prepared 27 May 2004