Bariatric surgery: more patient support needed

Bariatric weight loss surgery is too often thought of as a quick fix, with many patients undergoing operations without proper assessment of the risks that the procedure could pose, according to the findings of the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report Too lean a service? which was produced to look at variability and identify remediable factors in the process of care (from referral to follow-up) for patients undergoing bariatric surgery. The report focused on adult patients who underwent bariatric surgery between 1 June 2010 and 31 August 2010. Cases were limited to a maximum of three per surgeon per hospital. The age range of the study population was 18-69 years, with a median of 43 years. Approximately 80% of the patients were female, which is consistent with data published in the National Bariatric Surgery Register (NBSR).1 Weight loss surgery is an elective procedure and while there are NICE guidelines that identify patients that may benefit from this type of surgery, limitations on resources has meant that NHS commissioning bodies apply varying criteria, many of which are set at a higher threshold than those set by NICE, meaning that many patients do not have access to bariatric surgery funded by the NHS.2 This has resulted in many patients deciding to privately fund their procedure. The NCEPOD study found that 56% of patients had their surgery funded by the NHS, the remainder were privately funded. One of the key messages to come out of the report has been that those responsible for commissioning and delivering healthcare are struggling to resolve issues inherent in a surgical solution to a complex metabolic, social and behavioural problem. It is already well-established that bariatric surgery works. However the mechanisms by which surgical procedures lead to weight loss involve more complex changes in the controls of metabolism and satiety. It is the increasing availability of bariatric surgical solutions, in both the NHS and in the private sector, that has highlighted the severity of the problems associated with it. Report co-author and NCEPOD clinical co-ordinator in surgery, Mr Ian Martin, expressed concern that weight loss surgery was being seen, and often sold, as a quick fix to obesity problems: “Bariatric surgery is a radical procedure with considerable risks, as well as benefits. It should not be undertaken without providing full information and support to patients. However, when we reviewed cases for the report we found examples of inadequate processes from start to finish – even the basics, such as giving patients dietary advice and education before decisions to operate are taken, were sometimes lacking.”

Poor consent procedures

Mr Martin also highlighted concerns about the poor consent procedures in some hospitals and lack of psychological counselling prior to treatment: “Consent often happens on the day the patient is admitted for surgery. This means there is no time for them to reflect on their choice or have the opportunity to ask further questions about the risks and benefits of surgery before committing themselves to an operation.” The report also identified that only 29% of patients in the survey received psychological counselling prior to treatment. In contrast there is evidence to show that psychological disorders are common in obese patients who want surgery. A doctor who is seeking to treat the problems of their patient needs to understand them at an individual level. Treatment of one presenting symptom is neither safe nor reliable unless it is undertaken in the context of a confident assessment of the whole problem faced by the patient, said the report. In addition, one-third of the cases looked at in the report did not receive adequate follow-up after surgery, and nearly one-fifth of those patients had to be readmitted for treatment, with some people needing further surgery.