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A NICE example? Variation in provision of bariatric surgery in England

BMJ 2013; 346 doi: (Published 01 May 2013) Cite this as: BMJ 2013;346:f2453
  1. Amanda Owen-Smith, research fellow1,
  2. Ruth Kipping, research fellow and consultant in public health12,
  3. Jenny Donovan, professor of social medicine1,
  4. Christine Hine, consultant in public health3,
  5. Christina Maslen, clinical effectiveness research lead4,
  6. Joanna Coast, professor of health economics5
  1. 1School of Social and Community Medicine, University of Bristol, Bristol BS8 2PS, UK
  2. 2NHS North Somerset, Public Health, Clevedon, UK
  3. 3NHS Bristol and NHS South Gloucestershire Public Health Directorate, Emerson’s Green, Gloucestershire, UK
  4. 4NHS Bristol, Bristol, UK
  5. 5Health Economics Unit, School of Health and Population Sciences, University of Birmingham, Birmingham, UK
  1. Correspondence to: A Owen-Smith a.owen-smith{at}
  • Accepted 12 March 2013

Demand for surgery to treat morbid obesity outstrips supply. Amanda Owen-Smith and colleagues find regional commissioning policies are not consistent with NICE guidance and provision of surgery varies widely

The National Institute of Health and Care Excellence (NICE) has been the most ambitious attempt to set healthcare priorities more systematically and explicitly since the inception of the National Health Service in 1948.1 NICE was established in 1999 with the dual aims of reducing regional inequality in access to treatments and making decision making more systematic through explicit consideration of the clinical and cost effectiveness of (mostly) new treatments. Despite controversies related to the time taken to issue recommendations and the defensibility of its cost effectiveness thresholds, the NICE decision making process is respected within the UK and internationally.2 3

Nevertheless, NICE guidance has met with a mixed reaction from NHS commissioners, who have to implement the recommendations, some of which are mandatory within three months. Frustrations have arisen over the lack of consideration given to the affordability of implementation. (NICE recommendations have to be funded from existing allocations, implying disinvestment elsewhere.) Drawing on the example of bariatric surgery for morbidly obese patients, we review the implementation of NICE guidance and regional specialist commissioning guidelines over the past 10 years. We examine how they have affected provision of care and consider what challenges remain for the new clinical commissioning groups and NHS England as they take on their full commissioning roles.

NICE guidance

NICE issued mandatory guidance on bariatric surgery in 2002.4 The technology appraisal instructed primary care trusts (PCTs) to provide surgery for morbidly obese patients (body mass index ≥40 or ≥35 in the presence of specified comorbidities) when other interventions for weight loss had failed. Although PCTs were given some flexibility on the three month implementation schedule because …

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