Evidence from the Welsh Association for Gastroenterology and Endoscopy (WAGE) – ABS 06

WAGE_English and Welsh

Health and Social Care Committee Inquiry

Welsh Association for Gastroenterology and Endoscopy (WAGE) response to the Inquiry into provision of bariatric services in Wales

Response drafted by Mr Jonathan Pye MS FRCS

Past President of WAGE

incorporating the comments of WAGE Executive members

W.A.G.E. Response to the Inquiry into provision of bariatric services in Wales

Introduction:

1.1 Obesity is a modern epidemic that is a worldwide phenomenon in developed nations. A sedentary lifestyle with the easy availability of energy dense foods lends itself to the development of obesity and its most common co-morbidity - type 2 diabetes mellitus. Obesity is also associated with hypertension and heart disease, fatty liver and arthritis particularly of the lower limb. These are all long term conditions requiring large amounts of medical resource to manage effectively. Diabetes needs lifelong medication and medical supervision, and is the leading cause of blindness and kidney failure. Cardiovascular problems may be controlled by medication, but are normally associated with earlier death than a comparable population without such disease. Cardiovascular problems include widespread arterial disease, especially peripheral vascular disease (requiring amputation) and stroke. Fatty liver may overtake alcohol as the leading cause of cirrhosis and indication for liver transplantation in the years ahead. The knee and ankle problems develop because of the additional weight they have to bear. In addition, the pain from the arthritis then limits the normal first line treatment of effective exercise as part of a weight reducing regimen.

1.2 Wales has an obese population. Welsh teenagers come third in the world teenage obesity rankings. These are our young adults who are destined to add to the health cost burden on the Welsh Health Economy through a lifetime of diabetes, chronic liver disease, hypertension, sleep apnoea and joint problems requiring treatment. Welsh adults are further down the world rankings, but are ahead of the other UK Home Nations.

1.3 It is now beyond debate, with evidence from the UK and internationally, that the benefits arising from bariatric surgery are long-lasting, and that most bariatric interventions are cost effective if the correct population is selected for surgery. The intersection of the lines of cost of surgery and reduction in healthcare bills occurs between 2 and 4 years after surgery (3 years in the UK). At 2 years, 85% have had remission of their pre-operative type 2 diabetes. Furthermore, the Office of Health Economics in October 2013 suggested that bariatric surgery can pay for itself within one year as a result of not having to pay for the treatment of the co-morbidities caused by obesity.

2: Response of WAGE:

2.1 The Welsh Association for Gastroenterology and Endoscopy (WAGE) raised the matter of inadequate level IV care (on the all Wales obesity pathway) for patients with obesity via the Welsh Medical Committee in 2010. On 14th October 2010 the main theme of the Annual Scientific meeting of WAGE was the management of obesity. Dr Tony Jewell (then CMO WALES) was represented by Dr Sara Hayes, whose paper was entitled “Obesity: A Public Health Priority”. It seemed from her contribution that obesity was indeed a priority for the Welsh Department for Health and Social Services.

3: Subsequent developments:

3.1 On 4^th April 2012, the Welsh Medical Committee held a symposium specifically to review the management of obesity in Wales and to formulate recommendations, at the request of the Health Minister. The recommendations were forwarded to the Department of Health. The Chair of the Committee met with the Minister to discuss those recommendations.

3.2 Commissioning for bariatric services is under the auspices of WHSSC. Recommendations put to WG by WHSSC in January 2013 are straight forward, and are to be commended. The problem is that they have not been implemented to date. There is little evidence of either level III or level IV on the pathway being actively implemented in the management of obesity.

3.3In my original presentation to the Welsh Medical Committee, the evidence was that the number of cases referred for consideration of obesity surgery was 94 (in 2009) as compared with 445, 316 and 302 respectively in the English Health Authorities immediately adjacent to the Wales/England border. Although the Centre for Bariatric Surgery (WIMOS) has been established in Swansea, only 67 cases have been operated upon this year 2013/2014. The guidelines for access to surgery in Wales are so stringent that only very advanced cases are being funded. Unfortunately, such patients already have organ damage secondary to their type 2 diabetes and hypertension consequent upon morbid obesity, and are thus more likely to develop serious post-operative complications. Many audits and meta-analyses support the view that bariatric surgery is more likely to improve patient outcomes if undertaken earlier.

3.4 A parallel report is being submitted jointly by the Royal College of Surgeons of England (RCSEng) Professional Affairs Committee and the British Obesity and Metabolic Surgery Society (BOMSS) with further factual evidence that I will not duplicate in this paper as WAGE is fully supportive of the arguments outlined and the recommendations made.

3.5As WAGE pointed out some four years ago, the criteria for access to surgery in Wales are greatly more stringent than those recommended by NICE, and those criteria have not been relaxed to date. Also the All-Wales Obesity Management Pathway has not been implemented in full. This means that the Welsh Government is missing opportunities to (a) improve the health of its population and (b) to reduce its healthcare bill.

4. The current service:

4.1 WIMOS is established, but due to the restriction in funding is not able to work to its optimum capability. Patients from North Wales have to travel to England for bariatric surgery, but there is no co-ordinated referral system. If the access criteria are relaxed to somewhere near those advised by NICE, the benefits would be that WIMOS will be able to function to its optimal ability, and there will be a realistic opportunity to repatriate the North Wales patients to the upper G-I centre (in Wrexham), thus bringing more money back into Wales.

5. RECOMMENDATIONS

- Invest in obesity management to its fullest extent

- Relax the access criteria for obesity management/treatment

- Consider the establishment of a second specialist surgical multi-disciplinary team in North Wales, and possibly a third in South-East Wales.

Jonathan Pye MS FRCS

Past President of WAGE

January 2014