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

 

Focus group event, 12 March 2014

 

Members present: David Rees, Elin Jones, Lynne Neagle, Lindsay Whittle, Kirsty Williams, Gwyn Price, Rebecca Evans, Janet Finch Saunders.

 

As part of the inquiry into the availability of bariatric services, the Health and Social Care Committee hosted a focus group event on 12 March. The aim of the focus groups was to discuss bariatric services with patients, physicians, surgeons and allied health professionals who have direct experience of these services in Wales.

 

Four groups comprising a mixture of committee members, patients and health professionals were given one hour to discuss the following five questions:

 

1.   Multidisciplinary bariatric teams are made up of a variety of specialists and practitioners. What improvements, if any, could be made to patients’ access to these multidisciplinary teams, and weight management clinics, in Wales?

 

2.   Do you think current criteria identifying those who are eligible for bariatric surgery are adequate and appropriate?

 

3.   How are patients assessed for bariatric surgery and what problems are encountered?

 

4.   With regard to the treatment of patients with weight issues, is the level of training, information and support provided to health professionals adequate?

 

5.   What effect does weight management intervention, or lack thereof, have on the lives of patients?

 

The groups were invited to share their observations on each question in a subsequent plenary session.

 

NOTE OF PLENARY DISCUSSION

 

Question 1: Access to multidisciplinary teams and weight management clinics in Wales

 

Fragmented implementation

There was a clear consensus across the four focus groups that access to multidisciplinary teams and weight management clinics is inadequate in Wales. Reference was made to the existence of a “post-code lottery” for Welsh patients, with only Aneurin Bevan University Health Board currently providing a Level 3 service. Although participants praised the All Wales Obesity Pathway as a good strategic document, frustrations were expressed at the fact that its implementation remains piecemeal.

 

Timely access to skilled and specialist multidisciplinary teams

Participants noted that access to a multidisciplinary team comprising dietetic, psychological, clinical and fitness support is crucial to ensuring sustained weight loss for bariatric patients. The importance of having access to a skilled team with expertise in lifestyle change as well as dietetic and/or clinical interventions was emphasised. Furthermore, participants noted the need for timely access to the support of multidisciplinary teams – examples of significant waits due to the lack of Level 3 services were cited. Participants highlighted that delays in accessing services often perpetuated already complex and high-risk bariatric cases. There was consensus across the groups that access to specialist multidisciplinary teams is important both before and after bariatric surgery; post-operative monitoring and care was cited as a key factor in an individual’s ability to maintain a healthy lifestyle after surgery. Participants questioned whether adequate specialist resource is available currently in Wales given how few Local Health Boards have commissioned Level 3 services.

 

The role of primary care

The importance of ensuring “every contact counts” was highlighted and it was suggested that further work is needed to improve general practice’s approach to bariatric patients with many participants citing ignorance and prejudice as a barrier to accessing specialist services. Examples were given of patients having to request specialist weight management intervention as opposed to being actively offered support of this kind. In cases where general practitioners and primary care workers have a better understanding of the need for specialist bariatric intervention, it was noted that difficulties still remain with referring individuals to multidisciplinary teams due to the paucity of specialist weight management clinics. It was also noted by some participants that patients often see several general practitioners rather than the same individual – this can be unhelpful when seeking to establish which services are required.

 

Paediatric services

Participants emphasised that weight management issues often begin in childhood. It was highlighted, however, that weight management services are more limited for children than adults. There was consensus across the groups that specialist paediatric services ought to be provided to prevent or reduce the escalation of individuals’ weight management issues in later life.

 

Level 1 and 2 services

Reference was made to the recently developed ‘Foodwise for Life’ programme, an eight week structured weight management programme designed by public health dieticians in Wales. It was noted that this programme is designed to be delivered by a range of community-based staff, and to deliver services at levels 1 and 2 of the All-Wales Obesity Pathway. Reference was made to the possible contribution of third-party services such as Weight Watchers and Slimming World. Although it was acknowledged that for complex cases a more specialist approach is required, participants noted that a partnership approach with such schemes could be beneficial in order to avoid individuals reaching the point of needing the more specialist Level 3 and 4 services.

 

Question 2: Eligibility criteria for bariatric surgery

 

The need to adhere to NICE guidance

All groups agreed that there is a pressing need to work towards adherence to existing NICE guidance on bariatric surgery. It was emphasised that this is not currently implemented in Wales, although it is mainstreamed in England. It was noted that out of 1000 patients referred to Wales’s only provider of NHS bariatric surgery, 98% have not been eligible for surgery despite meeting the criteria outlined in the NICE guidance.

 

BMI and other co-morbidities

There was consensus that thresholds in Wales for accessing surgery remain too high. It was noted that the need for a patient in Wales to display additional co-morbidities and a higher BMI than in England in order to qualify for surgical intervention acted as a perverse incentive to individuals seeking bariatric surgery. Participants emphasised that it appeared people had to become more ill before meeting eligibility criteria, making surgery riskier for the individual and surgeons involved. The wisdom of applying such a high BMI and co-morbidity threshold in Wales was questioned.

 

Access to Level 3 support

It was emphasised by most participants that Level 3 and Level 4 services cannot be separated – a clear referral pathway is needed from Level 3 to Level 4, and vice versa, otherwise neither tier will work to its full potential. The importance of ensuring that all options are explored and exhausted prior to surgical intervention was highlighted. Most groups agreed that the requirement to participate for two years in a Level 3 scheme was sensible in principle as many people succeed in losing weight without surgical intervention during this period. It was also felt that this process would help ensure that those who are in most need of surgery actually receive it. There was consensus, however, that the criteria to participate for two years in a Level 3 service is too high a threshold when such services are not available on the necessary scale in Wales.

 

Age limits

There was consensus across the groups that bariatric surgery should only be available to patients under 18 years of age in exceptional circumstances as patients of this age are still growing. It was acknowledged, however, that the right support is needed promptly for children and young people – including access to specialist Level 3 services – in order to address weight management problems as early as possible. Although participants advocated the availability of specialist paediatric weight services in Wales, nobody was aware of any currently in existence here.

 

Question 3: Assessment for bariatric surgery

 

The role of Level 3 services

The important role played by Level 3 services in assessing the need for – and referring to – Level 4 services was emphasised by participants. As outlined in relation to question 2, however, the focus groups noted that the scarcity of Level 3 services in Wales impacts on the NHS’s ability to assess patients individually. It was argued that this has led to an inadequate level of assessment of individuals for bariatric surgery in Wales. There was a general consensus that referral for Level 4 surgical interventions should go through Level 3 services as outlined in the All Wales Obesity Pathway, but that the problem remains that Level 3 services are not available in the necessary quantity.

 

Post-operative care

It was emphasised that patients need to be fully briefed about the consequences of bariatric surgery and its associated risks, and the need to engage fully with a post-operative care regime. It was noted that a failure to commit to support services following bariatric surgery can have serious physical and psychological consequences.

 

Impact of refusal for surgery

It was noted that individuals are not always informed of the reasons why they are refused surgery. Participants felt that, if patients are refused, they should be provided with an explanation. Guidance about what steps they can take in the future should also be available. It was noted that many of those who are refused surgery in Wales travel over the border or further afield, often seeking private treatment. Examples of patients seeking cheaper treatment overseas from unscrupulous providers were given, with reference being made to the impact this has on the NHS when individuals return and require corrective surgery and/or treatment in Wales.

 

Excess skin removal

The importance of considering the impact of excess skin following successful bariatric surgery was emphasised. It was noted that, although excess skin removal is currently considered a cosmetic procedure unless specific physical complications arise, the psychological impact of excess skin on patients following surgery is significant. Participants believed that excess skin removal should be considered part of the health care of people who have undergone bariatric surgery, rather than as a cosmetic procedure. There was consensus among participants that excess skin removal ought to be factored in to all assessments and costs for bariatric surgery.

 

Cancellation of surgery

A number of participants cited examples of bariatric surgery, even once assessed as necessary, being cancelled. It was noted that cancellations arise due to bed capacity constraints, with other health conditions such as cancer and heart disease being prioritised.

 

Question 4: Training, information and support for health professionals

 

Training and support

Participants cited examples of healthcare practitioners displaying ignorance and prejudice towards obese individuals, with many patients being told to simply exercise and improve their diet. The need to train practitioners to improve their understanding of the underlying causes of obesity and raise their awareness of specialist services was emphasised. It was noted that some health professionals lack confidence when raising weight management issues with patients, and that training in this area is required, to reduce frustration for professionals and patients. It was noted that not enough focus is placed on the importance of training for health professionals, and that some GPs in particular may not have sufficient training or time resources to deal with complex weight issues. It was recommended that training about obesity, its causes and its treatment should be mainstreamed across all disciplines.

 

Skills mix

The importance of ensuring the correct skills mix among health professionals was emphasised by participants. The need for specialist training in the field of dietetics, psychology, and lifestyle interventions – including fitness – was noted. Some participants argued that there is a need to consider a different model of care to combat obesity, looking at the need to make lifestyle as well as clinical/physical changes. In this context obesity was likened to mental health conditions, where longer-term approaches and interventions – rather than diagnoses and one-off treatments – are required.

 

Question 5: The impact of weight management intervention, or lack thereof, on the lives of patients

 

Social

It was noted that successful weight management interventions can be life-changing, not only for patients, but for the whole family. Day-to-day tasks such as shopping, socialising, and travelling can all be restricted by obesity, which has a knock-on effect on an individual’s quality of life. It was suggested that equality impact assessments should include consideration of the needs of those who are overweight, as they do the needs of older people, linguistic needs or religious needs.

 

Physical

Participants noted that weight management interventions can have a significant impact on other associated conditions including diabetes, high blood pressure, sleep apnoea, joint problems and mobility issues among many others.

 

Economic

It was noted that many obese individuals may struggle to maintain a working life due to the physical and psychological impact of being overweight. The economic impact of this – both for the individual and society more widely  – was emphasised. The cost-benefits of bariatric surgery were emphasised with many participants noting that successful surgery can reduce costs including other health and social care expenditure and welfare payments.

 

Psychological

The relatively high incidence of depression among obese people was noted during discussions. It was emphasised that psychological support is needed for patients whether or not bariatric surgery is provided – it was noted that surgery alone might not improve a patient’s perception of their own body image, particularly if excess skin is not removed.