NHS commissioning groups restricting weight loss surgery, surgeons warn – at a cost to patients and the public healthcare bill

A freedom of information (FOI) request made to all NHS commissioning groups (CCGs) shows that several have adopted policies which attempt to ration weight loss surgery to the super-obese, and ignore official advice on who should be eligible for surgery.

This has made it more difficult for overweight and obese people to get effective treatment to help them lose weight despite evidence that it is safe, effective and saves healthcare costs, according to the findings of a joint report from The British Obesity and Metabolic Surgery Society (BOMSS) and the Royal College of Surgeons (RCS).

Some CCGs either require patients to stop smoking or for patients to have a Body Mass Index (BMI) of over 50, despite NHS England and the National Institute for Health and Care Excellence (NICE) stating that surgery is cost effective and should be considered for patients with a BMI of over 35 with a co-morbidity (a further medical condition) such as Type II diabetes, or a BMI of 40 without a co-morbidity.

NHS England is currently delegating the commissioning of bariatric surgery to CCGs although most groups (80%) have yet to decide their own policies. Six CCGs admit they are not complying with the NHS England and NICE guidance. East Riding CCG says patients must have a BMI of at least 50 before they will be considered for surgery. Wolverhampton CCG imposes the same condition but will also consider some patients at a lower BMI who have diabetes. Solihull considers patients at BMI 50 with certain co-morbidities and will consider patients at BMI 45 or higher who have diabetes. Vale of York will look at patients at BMI or 50 or more but will consider patients at a lower BMI with certain co-morbidities. Mid-Essex is restricting treatment to non-smokers at the time of referral and NE Essex says smokers must be referred to a cessation service before they can be considered.

BOMSS and the RCS are warning this could harm patients and are demanding they revise their policies to bring them in line with the official guidelines.

The report showed that most CCGs have not yet adopted their own bariatric surgery policies - but will have to do so by next month under a phased government NHS reform.

Shaw Somers, Consultant surgeon and BOMSS President, said: "Our survey reveals worrying evidence that some CCGs are effectively taking the law into their own hands and defying official guidance on surgical interventions which have been proved to help people with a serious medical condition and also save healthcare costs.

"It typifies the second-class citizen manner in which bariatric patients seem to be viewed by some CCGs.

"We are calling on NHS England and NICE to make it clear to CCGs that they must comply with the guidelines on who is eligible for this safe and effective treatment, not try to ration it in a misguided attempt to save money in the short-term.”

Royal College of Surgeons President Clare Marx said: “Study after study shows bariatric surgery is highly effective, particularly in treating type 2 diabetes associated with obesity. It is therefore astounding that commissioning groups are effectively indicating that obese patients should get even more obese before they will consider surgery. This makes no sense and contradicts our very strong public health messages about the benefits of losing weight. Bariatric surgery is a significant medical innovation which should be made available to those patients who meet criteria which NICE have considered and published.”

BOMSS and the RCS make five recommendations to health bosses.

•    The six CCGs with arbitrary requirements for bariatric surgery should revise their policies in line with national clinical guidance.

•    NHS England should reiterate that access to NHS bariatric surgical treatment should be based on clinical need and uniform across the UK.

•    NICE and NHS England should continue to highlight the benefits of bariatric surgery.

•    NHS England should confirm that all CCGs will be responsible for commissioning bariatric surgery from 1 April to address the confusion over who is responsible.

•    NHS England should provide CCGs with clinical guidance for commissioning bariatric surgery, in advance of the transfer of responsibilities.

As well as calling on the six CCGs to fall in line with guidance the RCS and BOMSS have pledged to review the policies of all CCGS once new commissioning rules are in place.

Notes to editors

Under a government reform announced two years responsibility for commissioning bariatric (weight-loss) surgery will have transferred from NHS England to all CCGs by next month (April).

For the survey the RCS contacted all 208 CCGs in England under the Freedom of Information regulations. 205 (98%) responded. Of those, 163 had not so far adopted their own policies for commissioning bariatric surgery. 36 had adopted policies that comply with NHS England and NICE guidance. 6 had adopted policies that did not comply with the guidance.
NHS England guidance says surgery should only be considered for people with a body mass index (BMI) of more than 40 kg/m2, or between 35 kg/m2 and 40 kg/m2 if they have other significant diseases. NICE says newly-diagnosed Type 2 diabetics with a BMI of between 30 and 35 should also be eligible.

The guidance says patients must have tried and failed to achieve clinically beneficial weight loss by all other appropriate non-surgical methods (Tier 3) and be fit for surgery (Tier 4).

The Royal College of Surgeons of England is a professional membership organisation and registered charity, which exists to advance surgical standards and improve patient care.

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