Intended for healthcare professionals


Postcode lottery persists over weight loss surgery despite NICE guidance

BMJ 2010; 340 doi: (Published 22 January 2010) Cite this as: BMJ 2010;340:c427
  1. Zosia Kmietowicz
  1. 1London

    Surgeons in England and Wales have called for clear rules on which obese patients are eligible for weight loss surgery on the NHS after a survey showed access to operations is “inconsistent, unethical and completely dependent on geographical location.”

    The survey of 43 bariatric surgeons practising in England and two in Wales found that while some patients with a body mass index (BMI) of more than 60 are being denied surgery others are being treated in the same hospital with a BMI of 40 or less.

    Guidelines from the National Institute for Health and Clinical Excellence (NICE) published in 2002, and strengthened in 2006, say patients with a BMI of 40 or more should be assessed for weight loss surgery.

    But primary trusts are interpreting the guidance any way they want, says the Royal College of Surgeons. Some trusts are not commissioning any obesity surgery, the survey found. In other areas trusts are referring only the most seriously ill patients—those with a BMI of 50 or 60 with obesity related illness. The survey also found that patients with lower BMIs, but still above 40, are being told they have to gain more weight or develop a life threatening illness like diabetes or stroke before they are put forward for surgery.

    Surgeons say no clinical evidence exists to support the practice of treating the most seriously ill. These patients have less to gain from surgery and are far more likely to have serious complications, they say.

    The college conducted the survey ahead of the first ever Annual Scientific Meeting of the British Obesity and Metabolic Surgical Society on 21 and 22 January. The 45 respondents perform 80% of weight loss surgery in England and Wales.

    Speaking before the meeting Mike Larvin, a bariatric surgeon and director of education at the college, said, “NICE guidelines are meant to signal the end of postcode lotteries, yet local commissioning groups are choosing not to deliver on obesity surgery. In many regions the threshold criteria are being raised to save money in the short term, meaning patients are being denied life-saving and cost effective treatments and effectively encouraged to eat more in order to gain a more risky operation further down the line.”

    An estimated one million people meet NICE criteria for obesity surgery and around 240 000 would like an operation, yet only 4300 weight loss operations were carried out on the NHS in 2009.

    Treating obesity costs £7.2bn (€8.3; $11.6) a year and delaying obesity surgery is draining NHS resources, say surgeons. They claim incontestable evidence shows that surgery is cost effective—with surgery costs recouped within three years as obesity associated costs are eliminated—and the only proved successful method of treating the morbidly obese.

    Surgeons are calling for the Department of Health to invest in a long term strategy to ensure that all patients have equal access to treatment by a multidisciplinary team in properly equipped centres. Treatment needs to be accompanied by long term follow-up and emergency readmission, they add.

    Peter Sedman, a bariatric surgeon, said that the society had been asking for “meaningful dialogue” with the Department of Health since 2006 to plan for the staffing needs to meet the demand for obesity surgery, but that it had not had a response. The 100 surgeons in England and Wales carrying out obesity operations would be insufficient to treat all those eligible under NICE guidance, he said.


    Cite this as: BMJ 2010;340:c427