National Assembly for Wales

Health and Social Care Committee

Inquiry into the availability of bariatric service

Evidence from WDLAG (Welsh Dietetic Leadership Advisory Group) and Welsh Board of the British Dietetic Association – ABS 13

Response to the inquiry into the availability of bariatric services Jan 2014 – WDLAG (Welsh Dietetic Leadership Advisory Group) and Welsh Board of the British Dietetic Association

1.  The effectiveness of specialist services at level 3 and 4 of All Wales Obesity Pathway in tackling the rising numbers of overweight and obese people in Wales

1.1 The All Wales Obesity Pathway (AWOP) describes services to be delivered at each level of the pathway from population level interventions at level 1 to very specialised bariatric surgery at level 4 with the idea being that numbers accessing services decrease as services target those with the most complex needs at they progress up the pathway.  Therefore we would consider the aim of level 3 and 4 services is to achieve weight loss with individuals with already very complex obesity related physiological and psychological health needs.  Achieving weight reduction, even at modest levels, has been shown to result in a reduced incidence of obesity related chronic conditions and to improve the management of chronic conditions, thereby resulting in reduced medication costs, reduced health professional contacts and unplanned admissions, reduced need for certain types of surgery such as orthopaedic surgery leading to a reduction in costs for the NHS.

1.2 It is interventions at levels 1 and 2 of the pathway that focus on preventing overweight and obesity from rising further and preventing individuals from needing to access more specialised services at levels 3 and 4 of the pathway.  That being said, the services at levels 3 and 4 are essential to manage the significant numbers of individuals with existing complex obesity related health needs who require significant input from the NHS to manage their obesity related co-morbidities and reduce their health risks, but this should be in parallel to effective delivery at level 1 and 2 to address the rising incidence of obesity.

1.3 Currently due to the restricted availability of bariatric surgery, focus is on those with most complex co-morbidities / higher Body Mass Index (BMI).  Further Investment in bariatric services would be required in order to offer to those at lower level of complexity / BMI, which would be better able to tackle rising numbers of ‘morbid’ obesity to bring individuals into a lower BMI category with corresponding reduction in health risk factors.  This however cannot be considered in isolation; current assessment and work up to referral to bariatric surgery requires investment in tier 3 service availability - i.e 'patients should have accessed specialist non-surgical weight loss services before referral to a bariatric surgical centre' (NICE 2006).Level 3 services are a critical gateway into bariatric services and are currently not available in all Health Boards across Wales.  WDLAG and the British Dietetic Association Welsh Board believe that level 3 services are critical to the delivery of the AWOP and that levels 1 -3 need to be in place prior to further development at level 4.

1.4 The NCEPOD (2012) report into the review of the care of patients who underwent bariatric surgery highlights the importance of effective pre-operative MDT assessment, with access to full range of MDT and a greater emphasis on psychological assessment and support for these patients at an earlier stage in the pathway.  It is also recommended that the specialist associations should provide guidance on the number of procedures undertaken by centres to ensure optimisation of outcomes.  This may support the argument for increased numbers of bariatric interventions, however not without equitable access to level 3 services.

1.5 The MDT post operative care of people undergoing bariatric surgery needs to be included in any future service plans to ensure that people who have undergone surgery have the appropriate  long term monitoring by suitably trained professionals. This support and expertise is not currently available through all local health board services and patients are being identified with longer term complications due to malnutrition associated with bariatric surgery.

1.6 It should also be noted that centres do have evidence of successful interventions supporting delivery of the AWOP, however within Wales the delivery of the pathway has received none of the resources required to deliver at the scale required to demonstrate the impact required.

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

2.1 Currently access to the above services is variable between Health Board areas, with ABMU (WISMOS) providing bariatric surgery for all of South Wales.  Access to, and availability of services at level 3 and level 4 is variable across Wales (as evidenced by the WHSCC Review of Bariatric Surgery Provision and Access Criteria in the Context of the All Wales Obesity Pathway, January 2013).


2.2 Public Health Wales (PHW), have recently been commissioned to undertake a mapping of current services at level 3 of the pathway.  The aim of this will be to have a nationally agreed common access and service specification for level 3 services.  This is due to be published in spring 2014.  On publication of this policy, consideration will need to be given to how this is funded across Wales.

2.3 NICE guidance specify that anyone with a BMI over 40 or over 35 with co-morbidities  is eligible for bariatric surgery (NICE, 2006).  However with 23% of the population of Wales (Welsh Health Survey, 2012) being obese, the NHS is not currently resourced to be able to meet this potential demand.  The Obesity Pathway specifies (in line with NICE guidance and NCEPOD report mentioned above), that individuals must have been through services at level 3 of the obesity pathway before they are eligible to be referred for bariatric surgery.  Therefore it is necessary to increase capacity at level 3 of the pathway to deliver evidence base and ensure equitable access to level 3 services across Wales, prior to, or alongside, increasing capacity at level 4 (bariatric surgery.  The aim of this would be to minimise the numbers needing to go on to have bariatric surgery, improve the appropriateness of referrals for bariatric surgery and maximising outcomes and provision of long term follow up care as appropriate.

3.  How services are evaluated and measured including in terms of delivering value for money?

3.1 Hywel Dda Health Board, and ABHB  have  a robust evaluation framework developed  to measure the effectiveness of services delivered at tier 3 as service provision is rolled out. ABMUHB and Cardiff and Vale do not have a level 3 service but  have a level 2/ 3 dietetic  programme withevaluation data. These will be shared across Wales as part of the Public Health Wales led work to support an evidenced based, equitable approach. 

3.2 In addition to clinical outcomes immediately post interventions, Health Boards should consider the wider impact weight management interventions have on NHS resource.  For example, clients achieving weight loss would expect to have an improvement in the management of their chronic conditions, a reduction in medication costs, a reduction in the number of health professional contacts or unscheduled admissions, a reduction in the need for some types of surgery, e.g orthopaedic surgery and a reduction in length of stay (NICE  Costing Report  Obesity: guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children  Dec 2006). 

3.3 We believe that in relation to bariatric surgery it should be common practice for the cost benefits of our clients who underwent procedures to be regularly reviewed, we have highlighted that we are not always aware of those accessing the service and therefore who is monitoring effectiveness and value for money etc.  This could be a consideration for support at an All Wales level (along side level 3 service evaluation if resource to deliver is made available).


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


4.1      As previously highlighted current resource is insufficient to meet need.  It is important to consider the need to increase and improve access across all levels of the AWOP and that an appropriately resourced equitable level 3 services need to be in place to maximise effective use of a level 4 service.


4.2 Any review of costs at level 4 need to consider the inclusion of plastic surgery costs for patients who have successfully lost weight and have excess skin that needs removing. This surgery is not currently available in Wales and has a significant impact on an individual’s physical and psychological well being.


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

5.1 Currently access varies across Wales depending on Health Board area.  Public Health are currently mapping at level 3 (as referred to previously), further detail available from WHSCC Review of Bariatric Surgery Provision and Access Criteria in the Context of the All Wales Obesity Pathway, January 2013.


Please Contact our colleague Zoe Paul-Gough with any further queries on 01267 227067