Health and Social Care Committee – inquiry into the availability of bariatric services

Visit to the Welsh Institute of Metabolic and Obesity Surgery, Morriston Hospital, 13 February 2014

Members present: David Rees, Elin Jones, Lindsay Whittle, Kirsty Williams, Gwyn Price, Rebecca Evans.

As part of the inquiry into the availability of bariatric services, the Health and Social Care Committee visited the Welsh Institute of Metabolic and Obesity Surgery (WIMOS), Morriston Hospital on 13 February 2014. The aim of the visit was to learn more about the service provided by Wales’s only NHS bariatric surgery unit.

The Committee met informally with members of WIMOS’s multidisciplinary team, including the Institute’s resident surgeons, physician, anaesthetist, specialist nurse, dietician, psychologist, theatre sister and surgical administrators, to discuss their work. A patient who had undergone bariatric surgery at WIMOS was also present and provided Members with an outline of her experience of bariatric services – including surgery – to date.

Welsh Institute of Metabolic and Obesity Surgery

The Welsh Institute of Metabolic and Obesity Surgery (WIMOS) at Morriston Hospital is the only provider of Level 4 bariatric surgery services in Wales. It was formed in November 2010 and undertook its first operations in January 2011.

WIMOS assesses all Welsh patients referred for Level 4 services in Wales against the criteria set by the Welsh Health Specialised Services Committee (WHSSC). In terms of undertaking surgery, WIMOS serves the south Wales population – the north Wales population is required to travel to England where services are commissioned at the Salford Royal NHS Foundation Trust. WIMOS provides a full multidisciplinary team, pre-operative assessment and follow-up service for two years following surgery and has access to two full-time consultant bariatric surgeons.

Note of Members’ discussion with WIMOS’s multidisciplinary team

This note outlines the themes discussed informally by Members and WIMOS’s multidisciplinary team during the Committee’s visit. Many of the issues discussed built on points made during the morning’s formal oral evidence session during which Mr Jonathan Barry and Mr Scott Caplin – both bariatric surgeons at WIMOS – gave formal oral evidence.

Eligibility criteria and service development

The disconnect between eligibility criteria in Wales and NICE guidance was highlighted during the visit to WIMOS. It was noted that fair and equitable access to bariatric surgery in Wales will not be achieved without adhering to NICE guidance, which sets lower criteria for access to surgery than that currently in place within the Welsh system.

WIMOS staff explained that the DUBASCO tool is used to identify those eligible for surgery in Wales. This is purely a rationing tool used to satisfy the requirement to operate on the specified number of patients commissioned by WHSSC each year – this figure was 67 patients (out of a potential caseload approximated at 3000) in the last year. It was noted that WHSSC is looking to commission an increased number of bariatric surgery procedures in future years. WIMOS staff noted, however, that there has been “inertia” with progress in this area.

It was noted at the time of the visit that the number of procedures that would be commissioned by WHSSC for the 2014-15 financial year were yet to be confirmed, but that an increase from 67 to 120 had been discussed. It was noted that, with the resource of the two available surgeons being used to full effect, WIMOS could do 240 operations each year. If Wales were to become NICE compliant, it was noted that a backlog of eligible patients would arise.

Treatment for children and young people

It was noted that surgery for under-18s is not currently permitted in Wales. The importance of ensuring that all patients – whether under or over 18 – have access to Level 3 services was emphasised. Staff commented that there is a growing number of obese children and young people presenting for treatment but no specialist paediatric Level 3 service is currently available in Wales. It was noted that WIMOS staff are often waiting for individuals to cross the line to 18 before anything useful can be done to assist them.

Allied services – dietetics, psychology etc.

The importance of the multidisciplinary approach to bariatric services was emphasised during the visit to WIMOS. The important role of the dietician and psychologist was emphasised and it was noted that patients are often referred to WIMOS having not had previous access to allied health professionals. This, in turn, can lead to inappropriate referrals to WIMOS for bariatric surgery before an individual’s lifestyle choices or psychological profile has been fully explored. It was argued that more adequate provision of Level 3 services could ensure that inappropriate referrals to WIMOS were reduced.

Impact of surgery

With regard to economics, it was noted that, in terms ofcost-benefit, there is a misperception that bariatric surgery is expensive. According to WIMOS staff, bariatric surgery becomes cost neutral within two and a half years of the procedure.  This is due to, for example, a subsequent reduction in other illnesses (e.g. diabetes) and the reduction in the volume of medication required by the patient. Committee members were also told that employment rates in the post-bariatric surgery population are the same as in the normal population.

In terms of physical impact, WIMOS reported an 85% remission rate for patients with diabetes, significant reduction in rates of hypertension and marked improvements in incidences of sleep apnoea. Members were also told that women undergoing bariatric surgery halve their risk of developing all types of cancer.

Reference was also made to a growing body of evidence that operating on obese women before they have children can reduce co-morbidities in their offspring.

Patient experience

During the visit Members met a patient who has undergone bariatric surgery at WIMOS. The impact of her obesity included orthopaedic problems that caused immobility and forced her to leave employment that she loved. She also suffered hypertension and depression as a result of her obesity and unemployment. She explained that her referral to WIMOS evolved via her GP and orthopaedic surgeon. The patient explained to Members that, post surgery, her life has changed dramatically. She has been able to undergo one knee replacement – this has improved her mobility, and another will follow shortly. The only remaining concern for her is the fact that she does not currently qualify for body contouring treatment on the NHS – i.e. excess skin removal – as this is considered cosmetic in her case.