Memorandum by Professor John Baxter (OB
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 nowa "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
The reasons for the poor performance of the
NHS in this area are the result of:
Lack of trained obesity surgeons
Lack of NHS capacityespecially
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 generalin particular lack of a regional plan
for obesity surgery
Prejudice by commissioners and health-care
staffin 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 servicesa
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
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.