Evidence from Welsh Health Specialised Services Committee– ABS 17

A Response to the National Assembly of Wales Health and Social Care Committee: Inquiry into the availability of Bariatric Services

1. SITUATION/INTRODUCTION

This paper responds to the specific questions raised by the National Assembly for Wales’ Health and Social Care Committee in relation to the provision of Bariatric Surgery for obese patients in Wales.

2. Background

The most cost effective means of providing services for overweight and obese people in Wales is a holistic approach to change the behaviour of the population as a whole in relation to diet, exercise, and lifestyles in general. Evidence from smoking cessation programs and other public health experiences confirms that an intervention is more likely to be effective if it is long term and multifaceted in nature, tackling multiple drivers and factors simultaneously[i].

The figure below shows the global determinants that affect the health of an individual and the population as a whole.

The determinants of health apply to obesity as they do to many other aspects of health, ill health and well being.

Assembly Members should therefore bear in mind that the national and local government possibly have more leverage to change lifestyle & behaviour at the population level than the NHS alone. NHS provision of bariatric services will only address a very small part of the population at risk and this will be brought to the attention of AMs during this inquiry.

Examples of population-level interventions that the National Assembly would be well placed to influence have been identified and are described below:

The enforcement of the Active Travel (Wales) Act 2013;
National Planning legislation to reduce the proximity of fast food outlets near schools, colleges, leisure centres and other places where children gather and to enforce mandatory Health Impact Assessment;
Lobbying the UK Government for a ban on the advertising of foods high in saturated fats, sugar and salt before 9pm; and an agreement from commercial broadcasters that they will not allow these foods to be advertised on internet ‘on demand’ services;
Lobbying the UK Government for taxation on sugary drinks of at least 20%;

Limitations on unhealthy foods available on NHS premises for visitors, patients and staff and provision of healthy alternatives, as adopted in some English hospitals;
The promotion of sustainable food networks across all of Wales – for example family based interventions or promoting local growing of food by individuals in allotments[ii]. The latter also addresses food poverty and the rising demand for Food Banks.

The conundrum that is faced by commissioners when considering how to tackle the rising tide of obesity is that lower risk populations need a broad approach to lifestyle change. The effectiveness of these approaches are harder to ascertain as it takes a longer time to show the difference and there are a number of overlapping interventions that have a huge effect.

In addition, there are specialist interventions for obese people that are more expensive per person, but are more likely to show a short term benefit which is easier to measure and ascribe to a single intervention. However, the specialist interventions are not cost-effective when aiming to modify the behaviour of large numbers of people.

3. QUESTIONS TO BE ANSWERED

3.1 The effectiveness of specialist services at Level 3 and 4 of the Welsh Government’s All Wales Obesity Pathway in tackling the rising numbers of overweight and obese people in Wales;

At an individual level, these services are effective in reducing weight in motivated patients. However at a population level, the provision of Level 3 and or level 4 services in isolation will not be effective at tackling the rising numbers of overweight and obese people in Wales. At present, there is a lack of an All-Wales Level 3 service and as such, demand for Level 4 Bariatric Surgery will outstrip supply at present and in the future.

The Welsh Health Specialised Services Committee (WHSSC) perspective on how to address this is to ensure that there is a synchronised balanced approach to the provision of obesity service levels 1, 2, 3 and 4 based on the needs of the population. This requires a synergy between commissioning at a WHSSC level and also at a health board level across Wales.

3.2 The eligibility criteria of patients and the availability of obesity surgery and specialist weight management services across Wales

The current eligibility criteria are:

• The individual is aged 18 years or over;

• The individual has received intensive weight management in a specialised hospital obesity clinic or a community-based equivalent;

• The referring clinician and the patient are in agreement about the referral; and

• The individual has a BMI of 50 or greater in the presence of a serious co-morbidity which may be amenable to treatment if obesity is modified through specialised obesity services.

WHSSC and relevant clinical teams are aware that this group of patients do not achieve the best outcomes and as such it is important to move the criteria to enable people with lower BMI’s to access the service. As a result, WHSSC is currently working to adopt the following criteria in the next commissioning year:

a. The individual is aged 18 years or over;

b. The individual has a BMI of 40 or greater, or a BMI of 35 to 40 in the presence of co-morbidity which would be expected to improve if obesity is modified;

c. Morbid/severe obesity has been present for at least five years.

d. The individual has received, and complied with, an intensive weight management programme at a multi-disciplinary weight management clinic (level 2/3 of the All Wales Obesity Pathway) for at least 24 months duration, but has been unable to achieve and maintain a healthy weight;

e. The individual is assessed using DUBASCO score (an international recognised standard risk assessment method); and

f. The individual is expected to gain significant benefit from bariatric surgery (assessed by the bariatric multidisciplinary team (MDT) at Welsh Institute of Metabolic and Obesity Surgery (WIMOS)).

This will only be effective if level 3 services are present across all of Wales and that demand can be met by supply (and available finances in a cash constrained NHS).

An all-Wales Level 3 service will act as a platform for pre-surgical management and post surgical support. This not only enables patients to attempt lifestyle interventions but also acts as a screening stage for assessing suitability for surgery. It will also help ascertain demand for bariatric surgery in the future and quantitatively inform WHSSC commissioning in subsequent years.

At present, there are 2 providers of Bariatric surgery that are commissioned by WHSSC. Abertawe Bro Morgannwg University Health Board (ABMUHB) and Salford Royal NHS Foundation Trust provide services for the populations of South Wales and North Wales respectively. WHSSC has agreed to a phased increase in Bariatric Surgery as described in the WHSSC commissioning plan for 2014/15.

3.3 Progress made by Local Health Boards on the recommendations highlighted within the Welsh Health Specialised Services Committee Review of Bariatric Surgery Provision and Access Criteria in the Context of the All Wales Obesity Pathway report;

Public Health Wales has drafted a service specification for the provision of Level 3 services in Wales. This draft service specification is currently being consulted on. The service will have to be costed and money found by LHBs to ensure that services are developed.

This will be challenging but Health Boards will need to acknowledge that provision of these services will result in cost savings to the NHS in the future. There is an urgent need for investment into Level 3 services across Wales.

WHSSC is working with Public Health Wales to ensure that the referral gateway between Level 3 and Level 4 service specifications are clear and agreed.

3.4 The effectiveness of specialist services, within Level 3 and 4 of the All Wales Obesity Pathway, in tackling the rising numbers of overweight and obese people in Wales; and how these services are measured and evaluated, including in terms of delivering value for money;

As stated above, the lack of an all Wales Level 3 service makes it difficult to respond to how the rising numbers of overweight and obese patients being addressed by Level 3 and 4 services. Once Level 3 services are in place, WHSSC will be in a better position to answer this question.

Data from the National Bariatric Database confirms that reductions in obesity, obstructive sleep apnoea, diabetes and hypertension have followed post surgery for a proportion of patients from Wales. Examples of this changes are that 53% of patients having weight loss and 61% having resolution of diabetes after one year of surgery. The detailed statistics relating to this have been excluded from this report for reasons of brevity and can be made available should the committee request. The results from the National Bariatric Database will be reviewed on an annual basis by WHSSC.

This dataset does not necessarily align itself with commissioning plans and as such WHSSC have introduced a series of Quality & Safety measures that are outlined below.

The effectiveness will be measured by the service specification which will be introduced in 2014 include the following:

Clinical Audit will be required, specified as follows:

The number of patients who had experienced the following post operation:

• Leaks at the anastomotic site;

• Incisional hernia;

• Post operative site infections;

• post operative pneumonia; and

• post operative mortality.

Clinical Outcome Audit

Bi-annual Audit of BMI change post operatively;
Quality of Life; and
An annual audit of EQ-5D, SF-6D or similar changes before and after.

Patient Experience

This will be measured using local tools or the validated CAREs tool[iii]. (http://www.caremeasure.org/).

These measures will be reviewed on an annual basis.

Deaths and serious adverse events are expected to be reported in real time (48 hours following the event) directly to the Medical Director and Head of Nursing and Quality, WHSSC.

The levels of investment currently allocated to provide bariatric surgery in Wales

In the current financial year, the allocations for Bariatric surgery are

Morriston Hospital for South Wales - £500K.
Salford Royal NHS Foundation Trust for North Wales - £250K.

The availability of obesity surgery and specialist weight management services across Wales

Patients from all over Wales are referred to the Level 4 service. The table below summarises the numbers of surgical procedures undertaken over the last 36 months by health board of residence at the above hospitals.