Experts recently argued that the U.K. National Health System (NHS) should increase bariatric surgeries from the current 6,000 to 50,000 a year to provide much needed health benefits for patients and to significantly reduce direct healthcare costs immediately and in the future.
The article, “Why the NHS should do more bariatric surgery; how much should we do?” was recently published in The BMJ, one of the world’s oldest general medical journals published in the U.K.
Bariatric surgery, commonly referred to as weight loss surgery, includes a several procedures performed on people with obesity. Weight loss follows after surgically reducing the size of the stomach with a gastric band; through the removal of a portion of the stomach (sleeve gastrectomy or biliopancreatic diversion with duodenal switch); or by resecting and re-routing the small intestine to a small stomach pouch (gastric bypass surgery).
Studies showed the procedures cause significant long-term weight loss, by as much as 25-35%. In addition, patients can better control or recover from Type 2 diabetes and reduce cardiovascular risk factors.
The cost of bariatric surgery can be recovered within three years by saving on medication prescriptions, daily monitoring of blood glucose, and improved physical activity which can help patients return to work and eliminate or reduce the need for disability benefits. To the contrary, bariatric consultant surgeon Richard Welbourn and colleagues maintain that as obesity rates are increasing, the number of NHS bariatric procedures are decreasing.
According to the article, bariatric operations between 2011-12 and 2014-15 had dropped 31%, from 8,794 to 6,032. Research further indicates that bariatric surgery threough the NHS is meeting less than 1% of the need – a stark contrast to surgeries in many EU countries. The U.K. has the second highest rate of obesity in Europe, and ranks sixth globally, with 25% of adults being obese and 62% being overweight (BMI> 25) or obese.
Overall, the U.K. ranks 13th out of 17 countries for bariatric surgery, and sixth among the G8 nations. Rates of bariatric surgery also vary within the U.K., with no NHS procedures available in Northern Ireland and few in Scotland and Wales.
“Given the severity of the problem, it seems urgent to consider the potential barriers to surgery,” the authors stated in a news release.
One reason behind low bariatric surgery rates in the U.K. is that general practitioners (GPs) are unable to refer patients directly to surgical services. Instead, patients must maneuver a tiered route. At tier 1, exercise and low-calorie foods are recommended. However, the majority of the patients will have been on diet for many years, with cyclical weight loss, reaching a plateau and then recovering the lost weight. Professional help may be allowed at tier 2 but some patients hesitate because of previous negative responses from health professionals, low self-esteem, or embarrassment.
The authors suggest “combining provision of secondary care medical and surgical management so that patients have access to surgical assessment earlier” and that “GPs and commissioners need to recognize the health benefits gained from bariatric surgery and the cost savings. This will facilitate better provision of secondary care services” and help address concerns of upfront surgery costs.
Stereotyping and prejudice can also have an impact and those opposed to bariatric surgery argue that it diverts attention away from prevention. Less than positive engagement at the primary care level may involuntarily encourage the problem.
“Adopting the phrase ‘metabolic surgery’ might enable society and patients to talk about it and begin to establish a culture change,” the authors suggested.
Improvement of obesity or metabolic care services for surgical follow-up in general practice could also improve care for individuals who do not want bariatric surgery. Given the limitation of available resources, acquiring helpful services may require disinvestment from other conditions, such as low risk gall stone disease or hiatal hernia.