Commissioning a bariatric surgical service for the treatment of people with severe obesity
Severe obesity is defined as a body mass index (BMI) of 35-39 kg/m2 (obesity II) with comorbidities, or a BMI of 40 kg/m2 or more (obesity lll). It is a chronic condition that is associated with an increased risk of morbidities such as type 2 diabetes, hypertension, cardiovascular disease, osteoarthritis, dyslipidaemia and sleep apnoea. Obesity is also a psychosocial and social burden, often resulting in social stigma, low self-esteem, reduced mobility and a generally poorer quality of life.
The full version of the clinical guideline on obesity states that there is increasing recognition both in the UK and worldwide that there is an ‘obesity epidemic'. Estimates suggest that more than 12 million adults and 1 million children in England will be obese by 2010 if no action is taken.
Surgery for the treatment of obesity, also known as bariatric surgery, is recommended as a treatment option for people with severe obesity when certain criteria are fulfilled. One of these is that all appropriate non-surgical measures have been tried but have failed to achieve or maintain adequate, clinically beneficial weight loss for at least 6 months. However, bariatric surgery is not generally recommended for children or young people.
Bariatric surgery is also recommended as a first-line option (instead of lifestyle interventions or drug treatment) for adults with a BMI of more than 50 kg/m2 in whom surgical intervention is considered appropriate.
The potential benefits of robustly commissioning an effective bariatric surgical service for the treatment of people with severe obesity include:
- achieving long-term weight loss in people with severe obesity and decreasing overall mortality after surgery
- reducing the development of new comorbid conditions and reducing healthcare use after surgery
- improving performance and patient-centred clinical care through implementing the recommendations for bariatric surgery and specialist dietetic follow-up outlined in NICE clinical guideline CG43 on obesity
- assessing service demand for people requiring bariatric surgery and specialist dietetic follow-up, and providing an opportunity for clearly defining the criteria for those requiring subsequent plastic surgery
- reducing inequalities by ensuring that all people who are severely obese have access to, and an assessment by, a multidisciplinary team
- ensuring the service is integrated and appropriate, and that clear referral pathways are in place so that bariatric surgery is provided alongside other clinical or public health weight management services and population health programmes
- increasing informed patient choice through the provision of information on a variety of procedures, thereby allowing the patient and clinician to jointly decide on the best intervention based on the best available evidence
- better value for money, through helping commissioners to manage their commissioning budgets more effectively - this may include opportunities for clinicians to undertake local or regional service redesign to meet local and/or regional requirements in novel ways.
Key clinical issues
Key clinical issues in providing an effective bariatric surgical service for the treatment of people with severe obesity are:
- using a multidisciplinary approach to accurately assess all people who are potentially suitable for bariatric surgery
- providing the best possible outcomes through the provision of evidence-based clinical care and postoperative follow-up in line with NICE clinical guideline CG43 on obesity
- ensuring that each surgeon in the multidisciplinary team has specialist experience in bariatric surgery and has undertaken a relevant supervised training programme
- ensuring that the service is integrated with other services for people with obesity and that regular specialist postoperative dietetic monitoring is provided
- providing a quality assured service.
National priorities and initiatives relevant to commissioning a bariatric surgical service for the treatment of people with severe obesity include:
- 'World class commissioning'.
- 'The NHS in England: The operating framework for 2009/10'.
- ‘National service framework for diabetes: standards',‘National service framework for coronary heart disease - modern standards and service models' and ‘National service framework for children, young people and maternity services'.
- ‘Delivering the 18 week patient treatment pathway'.
- ‘Commissioning framework for health and well-being'.
- Considering the impact of patient choice.
- The ‘Expert patients programme'.
- Implementation of NICE clinical and public health guidelines. These are currently core standards, and performance against these standards will be assessed by the Care Quality Commission in line with Standards for better health.
Although many or all of these priorities may be relevant to the services nationally, your local service redesign may address only one or two of them.
- Sjöström L, Narbro k, Sjöström CD et al. (2007) Effects of bariatric surgery on mortality in Swedish obese subjects. The New England Journal of Medicine 357: 741-52.
- Nicholas V, Christou MD, Sampalis J et al. (2004) Surgery decreases long-term mortality, morbidity and health care use in morbidly obese patients. Annals of Surgery 240: 416-24.
This page was last updated: 02 March 2012
- Bariatric surgical service
- Commissioning a bariatric surgical service for the treatment of people with severe obesity
- Specifying a bariatric surgical service for the treatment of people with severe obesity
- Determining local service levels for a bariatric surgical service for the treatment of people with severe obesity
- Assumptions used in estimating a population benchmark
- The commissioning and benchmarking tool
- Ensuring corporate and quality assurance