http://www.sundayherald.com/38057
By the time patients are sent to surgeon Duff Bruce for controversial stomach stapling operations they have tried and failed every other way to shed the excess pounds which put their lives at risk. Efforts to persuade them to eat a healthy diet and take exercise have had no effect and they have not responded to even anti-obesity drugs.
Weighing in at around 20 stones, often at risk of heart disease, diabetes and joint problems, these patients have self-esteem which is so low that they are unlikely to have a job. Some are too embarrassed even to leave their homes.
Surgery to shrink the size of their stomachs is the last resort and even when they are referred to Bruce in Aberdeen, they can face a wait of around two years. Those who manage to get on to a waiting list for obesity surgery in Scotland are the lucky ones. Doctors in Glasgow have been told to stop adding patients to the list. Instead, they are told just to hold on to the names – “put their names in a box’’ is how one consultant described the order.
Only around 150 operations for obesity are carried out in Scotland every year. According to government guidelines, almost three times that number should be performed. But each operation costs at least £7000 and there remains a public perception that the surgery is cosmetic and panders to a problem that patients have brought upon themselves.
It’s hardly surprising that health chiefs are reluctant to divert the cash from “more deserving” illnesses such as cancer and heart disease.
Obesity surgery is only recommended for patients who are severely or ‘‘morbidly’’ obese, with a Body Mass Index (the ratio of weight in kilos over height in metres squared) of over 40, or over 35 if they have other serious health complications. A man at the average height of 5ft 9in would become morbidly obese when his weight hits 20 stones. Around 660,000 people in the UK are classed as morbidly obese, but only patients who have attended a specialist obesity clinic and have tried all other treatments, including drugs, would be considered for surgery.
It can be highly effective. Patients shed between 35% and 60% of their excess weight in the two years following their operation.
But the cost is prohibitive and as there are no dedicated obesity surgeons in the UK, doctors would need to be diverted from treating other patients, which would be certain to prompt protests from critics who believe that obese patients should learn to control their eating habits and not expect the NHS to deal with their over-indulgence.
Although the most common type of surgery carried out in the UK is restrictive surgery which involves reducing the size of the stomach by stapling or banding, another approach allows patients to continue eating as much as they like. The procedure, known as malabsorptive surgery or gastric bypass, involves diverting food from the gut directly to the bowel so that less is absorbed into the body. Patients can then eat unrestricted amounts as they do not process it to produce fat.
Duff Bruce, a consultant surgeon at Aberdeen Royal Infirmary, argues that once the weight loss is kick-started by surgery, patients become less of a burden on the NHS because they do not develop obesity-related illnesses such as heart disease and diabetes.
“When people get to that weight it is very difficult for them to lose it. There is a lot of bias against these patients.
“At that amount of weight loss there is good documentation that a lot of the common problems of obesity will also decrease such as diabetes and hypertension, heart disease and joint disease. There is also a dramatic improvement to the patient’s quality of life and circumstances. Patients are more likely to get a job. There is also a decrease in the contact with the medical services.”
From next year, the number of stomach stapling operations carried out within the NHS in Scotland is set to double. The Scottish Executive has set up a special group to plan the expansion of obesity surgery across the country and this is expected to result in creating three specialist centres where the operations will be carried out.
Guidelines issued last year by the National Institute of Clinical Excellence (Nice) said the treatment should be available to up to 4000 patients in England and Wales, which would equate to over 400 in Scotland where there are higher levels of obesity. The guidelines were later adopted by the Health Technology Board for Scotland.
Doctors with an interest in bariatric surgery (surgery for obesity) have met with civil servants to plan where specialist obesity clinics offering stomach stapling operations should be set up. Clinics are expected to be established in Aberdeen and Glasgow with a third either in Edinburgh or Dundee.
And in anticipation of the national expansion of obesity surgery, Grampian University Hospitals NHS Trust has funded a new programme which will be run between Aberdeen Royal Infirmary and Dr Gray’s Hospital in Elgin from January.
Duff Bruce has been developing the programme with his colleague Jack Miller, who is based in Elgin. “Since the Nice guideline came out the Scottish Executive has been trying to identify sites,’’ says Bruce. “There will be three or four in Scotland. At the moment the Scottish Executive is meeting to decide how best to allocate the resources. There will be between two and four centres. At the moment they are actively trying to identify the most suitable sites.
“The Nice guidelines, issued last year, were the first centrally documented support for the use of obesity surgery. The Scottish Executive is supporting this.
“We have been working with our trust to get funding for this and we will start keyhole obesity surgery in January. We have been backed by our trust. Grampian University Hospitals NHS Trust is running a pilot scheme.”
Professor Iain Broom, who treats obese patients in Aberdeen, will refer patients who have not managed to lose weight through diets, exercise or drugs to Bruce and Miller. Although a small amount of obesity surgery has been carried out in the past, he would welcome an expansion and formal backing from health boards and the government.
“These operations have been carried out but we don’t have a formal bariatric service and there is a need for it. At Grampian University Hospitals NHS Trust there is a two-year waiting list. There are huge waiting lists because there are few centres across the UK carrying this out.
“I know that some individuals have gone abroad to have this done. Some have gone to France. There is a patient-led and clinical need for this.
“We are in discussions with the Scottish Executive. A committee is looking at the current provision and whether surgery programmes need to be set up and funded.”
The Scottish Executive is considering setting money aside for the clinics which would receive patients from across Scotland.
“This would be a tertiary referral service,” adds Broom. “For this to take place we need specialist obesity centres. The surgery would need to be backed up by multi-disciplinary obesity teams.”
David Galloway, a consultant surgeon at Gartnavel General Hospital in Glasgow, says we should be carrying out “several hundred” stomach stapling operations a year in Scotland. “Now there is at least an intellectual acceptance that we have got to do more. The Chief Medical Officer is going to need to work out how we are going to deliver it. It will need to be driven by political will and resources.
“I do think there is a clinical need. We would only regard surgery as a last resort but it does seem to work and work well. Surgery is going to feature more and more. Potentially we are talking about several hundred in Scotland. At the moment, we do not have the resources to get to that level.”
The health service’s real fear is that demand will rise even faster if patients become aware that obesity surgery is routinely available in the NHS hospitals, which would then be inundated with requests.
“Instead of having 30 to 40 patients on the waiting list they could have 5000,’’ says Ross Carter, a surgeon at the Royal Infirmary in Glasgow who performs a small amount of obesity surgery. “Given the epidemic we are only ever going to be able to give surgery to a small proportion of those who would benefit. Within Scotland there may be several hundreds of thousands of patients that we could justify this surgery for, but there is no way we could do anything like that number. We could clinically justify several thousand a year. We will always be able to treat just the tip of the iceberg but we could double the number we are doing within Glasgow.”
In Glasgow, obese patients are only put on the surgery waiting list if they have another serious health problem and need to lose weight in order to be treated.
Carter adds: “There are very few patients going on the waiting list. They can do so only if they have a major medical problem that they cannot get treated unless their weight is reduced. We can justify that.”
Professor Mike Lean, head of human nutrition at Glasgow University, treats obese patients at Glasgow Royal Infirmary. He sees hundreds of patients whom he believes would benefit from surgery but have little hope of getting it. He would welcome a significant increase in the number of operations.
“We have hundreds of patients waiting for surgery with no prospect of them being called. These are people who we have assessed as suitable for surgery.
“Because surgery is effective we cannot ignore it. We have got to give it to those who derive the greatest benefit.
“Glasgow Royal Infirmary has told us not to put patients on waiting lists but just to take a note of them. We are meant to keep the names in a box.
“The number of operations taking place at the moment is minuscule because the surgery is expensive but hundreds of patients would benefit from this surgery in Scotland every year.”
The Scottish Executive thinks the issue is serious enough to review the services across Scotland.
A spokesman said: “We recognise the need for surgery as a treatment for the morbidly obese. A working group on bariatric surgical services has been set up by the Scottish Medical and Scientific Advisory Committee (SMASAC) to review the organisation of these services in Scotland. We expect the group to report by summer next year.”
Obesity: Under The NHS Knife
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