Health and Social Care Committee
Inquiry into the availability of bariatric service
Evidence from Aneurin Bevan University Health Board– ABS 15
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Our Ref: AG/JS-sm |
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24th January 2014 |
Committee Clerk
Health and Social Care Committee
National Assembly for Wales
Cardiff Bay
CF99 1NA
Dear Sirs
Re: Inquiry into the Availability of Bariatric Services in Wales: Evidence Submission from Aneurin Bevan University Health Board
1. Introduction
1.1 ABUHB welcomes the opportunity to respond to the Inquiry into the Availability of Bariatric Services in Wales
1.2 Aneurin Bevan University Health Board (ABUHB) is responsible for the planning and delivery of primary, community and secondary care health services for the populations of Caerphilly, Monmouthshire, Newport, Blaenau Gwent and Torfaen, and also provides secondary care services for South Powys and other border areas. ABUHB serves a population of approximately 600,000 people and employs 14,000 staff.
2. Historical Service Provision for Obese Patients within ABUHB
2.1 In 2009 a National Public Health Service analysis of Welsh Health Survey data found that across the former Aneurin Bevan Health Board (ABHB) population circa 205,000 adults were overweight or obese (BMI of 25 or more). Of these, approximately:
- 72,000 had a BMI of 30 – 39
- 6,000 had a BMI of 40 – 49
- 700 had a BMI of 50 or more
2.2 In 2011 obesity services in ABHB were mapped against the All Wales Obesity Pathway. A range of services were being provided across levels 1 to 3; via primary care, dietetics, clinical psychology, exercise on referral and one consultant physician. However, there were inequities and gaps in service provision and a lack of coordination across the Health Board. Two separate level 3 services were in existence.
2.3 The first level 3 service was a weekly Consultant Physician led clinic supported by dietetic, cognitive behavioural therapy, nursing and physiotherapy services. This clinic was initiated around 2004, with funding from the Welsh Assembly Government ‘Inequalities in Health’ grant to Blaenau Gwent Local Health Board in 2003. This service built up a considerable waiting list when it was opened up to all ABHB residents in 2010. It was greatly lacking in administrative support, and had limited outcome and audit data available for the clinic. Eligibility criteria were patients aged over 18 with a BMI of at least 40, or at least 35 plus co-morbidity. A recent medical student audit showed successful outcome, in terms of weight loss of at least 5% of starting weight, were achieved by at least 50% of 100 patients who attended for at least one year, with many of these achieving much greater losses.
2.4 The second level 3 service operated between 2010 and 2013, for Torfaen County Borough adult residents, funded through a fixed term British Heart Foundation (BHF) grant. This was a multidisciplinary service comprising a GP, a consultant psychologist, a senior nurse, a dietician and an exercise therapist. This service closed when of BHF funding ceased in 2013.
2.5 A total of 523 individuals were referred into the BHF level 3 services during the project. Of these, 442 attended an initial assessment, 379 agreed to attend for therapeutic intervention, and 259 actually received interventions, including further appointments to discuss progress.
2.6 Of those that progressed to therapeutic intervention, 74% had a BMI of 40 or more, with 20% having a BMI of 50 or over. At three months after the start of a therapeutic intervention 28% had lost at least 5% of starting body weight; with 61% having done so at six months, and 50% at one year.
2.7 Level 4 services are commissioned from the Welsh Institute of Metabolic and Obesity Surgery (WIMOS) in Swansea via the Welsh Health Specialist Services Committee (WHSSC). Twelve patients have received NHS provided bariatric surgery. Residents also accessed bariatric surgery through private providers both locally and elsewhere.
2.8 The numbers of patients accessing level 2 and 3 services at this time were circa 1% of the obese adult population within the ABHB area. There was a wide discrepancy between the numbers who would benefit from obesity services and actual service capacity at all levels.
3. Current Development of Obesity Services in ABUHB
3.1 During 2012, detailed work was undertaken within the Health Board to define a new co-ordinated, fully integrated service model for adult weight management.
This new model, which incorporates and expands upon existing services, was approved by the Health Board in July 2013 and additional funding agreed in September 2013 to facilitate its implementation. Some non-recurring funding has also been agreed form the BHF for the current financial year.
3.2 The additional funding will enable the appointment of a non-medical professional programme lead, additional clinical psychology and dietetic input and adequate administrative support to the service.
3.3 The new model incorporates an integrated patient pathway via a single point of access to specialist services at levels 2 and 3, as described by the All Wales Obesity Pathway. The service will be available to adults with a BMI of 30 or more. The introduction of an initial clinical assessment for all patients at service entry will enable individuals to be allocated to the most appropriate clinician / team in a timely manner. Options available will include dietetic-led Slim for Life group education sessions, structured 1:1 education sessions with a dietician, clinical psychology support and a level 3 multi-disciplinary clinic. Existing links with the National Exercise on Referral Scheme (NERS) will also be maintained enabling access to this service. The allocation of patients to specific elements of the service will be mutually agreed between the patient and a health professional.
3.4 The integrated nature of the new service model will facilitate patients to move easily between elements of the pathway as and when required and should also facilitate appropriate access to level 4 services.
3.5 In addition to generic weight management support, the service will specifically support obese individuals with osteoarthritis of the hip and knee in an attempt to reduce the need for joint replacement surgery. The team will also provide support and education to other clinicians.
3.6 Phase one of the new service model was implemented within Torfaen in December 2013. The service will be extended to Blaenau Gwent residents in February 2014 with access for Caerphilly, Newport and Monmouthshire residents planned from April 2014.
3.6 The new service will consolidate current capacity, provide some additional capacity and create a foundation for future evaluation and expansion.
4. Level 4 Services (Bariatric Surgery)
4.1 Bariatric surgery for ABUHB residents is currently commissioned through WHSSC in accordance with the WHSSC commissioning policy and criteria.
4.2 With the implementation of the new service model within ABUHB, future referrals to level 4 services will be directed through the level 3 multidisciplinary clinic.
4.3 The current WHSSC commissioning policy sets out a number of ‘qualifying’ criteria including age over 18, prior intensive weight management in a specialised clinic, a BMI of 50 or greater, together with a serious co-morbidity which may be amenable to treatment if weight loss is achieved.
4.4 The WHSSC criteria differ from NICE guidance, which sets a lower BMI threshold and also recommends consideration of bariatric surgery as a first-line option for adults with a BMI of more than 50.
4.5 There is professional concern that the strict nature of the current criteria means that those people who do undergo NHS surgery may be at considerable risk from the surgery due to their high BMI and the severity of the co-morbidity required to meet the eligibility criteria.
4.6 Due to the current access criteria there is a cohort of patients who do not meet the current criteria who would benefit from bariatric surgery. Some patients will elect to access surgery privately, the standards of which will be out with the HBs influence. Any complications arising from private treatment however may require NHS management thus presenting a burden on local services.
4.7 There is anecdotal evidence that some individuals feel the need to gain weight, in the belief that they may have a better chance of accessing NHS surgery. It is difficult to ascertain how many individuals really believe this, or whether it is being used as one of the many ways in which some patients consciously or otherwise avoid taking action to change their behaviour to initiate weight loss.
4.8 In view of the evidence of effectiveness and positive cost benefit associated with bariatric surgery, it is considered that the current criteria should be aligned to the NICE guidance. However the cost and effect on demand for level 4 services needs to be recognised and may require a staged approach to enable deliver.
4.9 In addition to the direct surgical costs of current and increased demand for level 4 services, consideration must be given to the provision of appropriate post-operative follow up care not only by the specialist tertiary service but also within the referring Local Health Boards.
4.10 An additional area of concern relates to the surgical removal of ‘fatty aprons’ created by rapid weight loss after bariatric surgery. This is not currently funded by Health Boards unless there is intractable infection present. Consideration should be given to providing this intervention for patients presenting with this uncomfortable and disfiguring side effects of significant weight loss. It is recognised, however, that, slow weight loss engendered through intervention at Levels 2 and 3 is less likely to result in this problem.
5. Future Investment in Bariatric Surgery in Wales
5.1 WHSSC invested £0.500m into the ABMUHB service in 2010-11 to provide a bariatric service to South Wales. The baseline activity for this service is as follows
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Description |
Activity Baseline |
2013-14 Year to Date Activity (November 2013) |
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Intragastric Balloon |
5 |
0 |
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Sleaves/Bypass |
44 |
25 |
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Revision of Banding |
3 |
5 |
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Removal of Banding |
11 |
6 |
5.2 For 2013-14, ABUHB are responsible for an 11% risk share of any over or under-spend against this service. As at January 2014, the ABMUHB service is not anticipated to overspend.
5.3 Prior to the investment in ABMUHB, the service was provided by North Bristol NHS Trust with 6 ABUHB patients currently being followed up at North Bristol NHS Trust to maintain continuity of care.
5.4 In the 2014-15 WHSSC Plan, a cost pressure of £0.160m has been included in respect of the ABMUHB Bariatric Service of which £0.018m has been attributed to ABUHB. Further details in regard to the proposed investment have been requested from WHSSC.
6. Summary
6.1 ABUHB fully recognised the value of the All Wales Obesity Pathway and is taking action to re-align its services to the pathway, including primary care initiatives at level 1 and enhanced adult weight management services at Levels 2 and 3.
6.2 ABUHB believes that a review of the criteria for bariatric surgery is timely.
Yours Sincerely
Dr Andrew Goodall
Prif Weithredwr/ Chief Executive
Welsh Assembly Government (2009) The Evaluation of the Welsh Assembly Government Inequalities in Health Fund 2001-2007 Executive Summary: WAG
http://wales.gov.uk/topics/health/improvement/index/report/?lang=en
Welsh Assembly Government (2010) All Wales Obesity Pathway. Cardiff: WAG
http://wales.gov.uk/topics/health/improvement/index/pathway/?lang=en
WHSSC Commissioning Policy for Bariatric Surgery (CP29), 2009
Van Woerden, H, (2009) Comparative epidemiology of overweight and obesity in the UK, NPHS Wales, March 2009