Making difficult decisions - Obesity Treatment Eddie Coyle Jane Bray Sara Davies David Cline Jennifer Armstrong Heather Knox

Background National Planning Forum (NPF) requested by Scottish Government’s Route Map to establish a subgroup to provide advice on how NHS Scotland should respond to growing demand for bariatric surgery, including need for weight management. OTS set up June ’10 Membership: clinicians, public health, SG, planners, QIS, primary care, patient reps, ethicist

Obesity Treatment Subgroup ( NPF OTS) Remit: Inform prioritisation of planning provision of treatment for severe and complex obesity in adults Working methods: Evidence gathering from experts; review of research evidence including cost effectiveness; development of range of options for NPF and board Chief Executives to consider.

Obesity Facts Scotland has second highest prevalence of obesity in the world at 27% (1.1 million people) 8.4% population BMI ≥ 35 (347,000) 2.4% population BMI ≥ 40 (103,000) Epidemic expected to peak at 40% (2030) Severe obesity prevalence is increasing at 5% per year 50% of all obese people have significant health problems - co- morbidities

Obesity Pathway ‘route map’ Tier 1Population-wide health improvement work Tier 2 Primary care e.g. Counterweight Tier 3Specialist Weight Management »Management of severe and complex patients »Gatekeeper for surgery Tier 4Specialised surgical service »Ante and post surgery »Actual operations

Evidence Base: Tier 3 specialist weight management Weight management is clinically effective compared to no treatment (5kg, 2-4 yrs) Cost effectiveness evidence is limited, but suggests cost effectiveness Small weight loss of <5kg can reduce co- morbidities such as diabetes

Evidence base: Tier 4 Bariatric surgery Bariatric surgery is highly clinically effective and cost effective for achieving wt loss (25-75 kg, 2-4 yrs) 75% of initial wt loss sustained at 10 years Cost effectiveness is greatest for BMI>40 or BMI comorbidity £1,400 per QALY at 20yrs for BMI and diabetes

Needs Assessment: Tier 3 Weight Management Variable provision across Scotland Estimated population need /100,000 Essential both for –treating obesity not managed in primary care –and to provide support mechanism to manage demand for surgery

Comparative numbers (rates) of bariatric surgery Sweden: 4,879 (52.7/100,000) England: 6,520 (10.6/100,000) Scotland: 197 (4.6/100,000)

NPF/OTS: Evidence Summary Outcomes: Strongest evidence for bariatric surgery - £ £4000 per QALY at 20 years (T2DM and BMI 30-40; or BMI>40) Evidence of clinical effectiveness for Tier 3 but little on cost effectiveness

NPF/OTS: Pre Surgery Principles Build on existing services Tier 2 – in all NHS Boards Tier 3 – consider different models (could be shared provision across boards; use of existing staff would reduce costs) Referral to Bariatric assessment from T3 –Success weight loss is criteria

NPF/OTS: Bariatric surgery ‘Ante’ and ‘post’ Bariatric with the surgical service Clear pre and post assessment and management protocols Concentrate in centres with at least 2 surgeons with minimum of 20 cases each per year with networking Audit: equity, access, outcomes Revisit by April 2013

Tier 4 Bariatric surgery - models Seminar required – NPF/OTS - to get buy in to evidence and agree models, due to varied opinions of planners, clinicians and particular concerns re-financial impact. The 3 models are : 1. “Framework without criteria” 2. “Framework with topped criteria” 3. “Framework plus Type 2 Diabetes” -3B = Modified with tighter criteria All models can be flexed to address case by case

Obesity Options: criteria and estimated demand Option 1 Option 2 Option 3 43,182 Minimise risk? 16, Prioritise T2DM? No Yes No BMI = 375 BMI = 250 “Framework without criteria” “Framework with topped criteria” “Framework plus Type 2 DM” - BMI >35 - Age ≥18 - At least one co-morbidity - Age years - BMI BMI - At least one co-morbidity. - Recent (< 5 years) onset of Type 2 diabetes mellitus, in addition to Option 2 age/BMI criteria

Table 1 : Estimated impact of models (bariatric surgery only) Impacts for Scotland on adult population Current practice Procedures in 2009/10 Option 1 Framework without criteria Option 2 Framework with topped criteria Option 3 Criteria- T2DM Option 3B Modified criteria for Option 3 – BMI Number of patients 19743,18216, Rate /100, , Cost range (band & bypass) £1-2.2 million £ million £ million £3-7 million £ million

Summary Primary care and specialist weight management services –Primary care services in all health board areas –Tier 3: As local as possible but cross Board provision should be explored –Use existing staff and consider role of technology Surgery –pre and post surgery weight management services should be co- located with surgery in centres with at least 40 cases per year and 2 surgeons –Criteria with case by case flexibility

Outcome: NPF/OTS Planning principles agreed Preferred option – option 3B i.e. smallest numbers (important to emphasise that this recommendation includes increase in rate to minimum 9/100,000 in all boards) Regional approach to planning Tiers 3 and 4 services agreed

Next Steps Communication of NPF agreement to all boards: aim is to keep clinicians, planners, CEs bought in to this national agreement and ensure changes are made Implementation arrangements to be made by boards Monitoring and feedback to NPF 2013

Health and equity impact assessment Current Access Access to surgery very varied between health boards Men - approx 25% of wt mgmt and surgery Other groups e.g. ethnic minority, carers, mental health problems - access unknown Bariatric surgery requirements for attendance may exclude many e.g. carers, remote/rural, those with mental health problems, lower socioeconomic groups

Health and equity impact assessment cont. Recommendations Communication strategy – to reduce stigma and discrimination around obesity Equity of access to services required across Scotland including rural/remote Careful patient selection to reduce adverse outcomes Family involvement recommended in order to provide appropriate support

Health and equity impact assessment cont. Recommendations cont Alternative services needed for those unable to comply with behavioural change and follow up required for surgery Men – single sex groups, internet groups may be beneficial. Staff training needs assessment required to determine staff training needs Additional research required on needs of men, ethnic minorities, antenatal women, those with learning disabilities