Developing Integrated Clinical Pathways for the Management of Clinically Severe Adult Obesity: a Critique of NHS England Policy

Abstract

Purpose of the Review Pathways for obesity prevention and treatment are well documented, yet the prevalence of obesity is rising, and access to treatment (including bariatric surgery) is limited. This review seeks to assess the current integrated clinical pathway for obesity management in England and determine the major challenges. Recent Findings Evidence for tier 2 (community-based lifestyle intervention) and tier 3 (specialist weight management services) is limited, and how it facilitates care and improve outcomes in tier 4 remains uncertain. Treatment access, rigidity in pathways, uncertain treatment outcomes and weight stigma seems to be major barriers to improved care. Summary More emphasis must be placed on access to effective treatments, treatment flexibility, addressing stigma and ensuring treatment efficacy including long-term health outcomes. Prevention and treatment should both receive significant focus though should be considered to be largely separate pathways. A simplified system for weight management is needed to allow flexibility and the delivery of personalized care including post-bariatric surgery care for those who need it.

The Effect of Participation in Tier 3 Services on the Uptake of Bariatric Surgery

“…In essence, the findings of our study should be used to support the principles of tier 3, rather than accepting the current structure of obesity service. Our opinion aligns with that of Hazlehurst et al [ 11 ] in that pre-tier 4 services should be more efficient in identifying and preparing patients who wish to proceed to surgery rather than insisting on barriers to surgery such as a certain time or percentage weight loss during the tier 3 programme. During this period, patients’ expectations of surgery can be managed [ 19 ], with realistic goals outlined.…”

“…In a review of the current NHS England policy on obesity services, Hazlehurst et al [ 11 ] concluded that tier 3 services would not reduce the proportion of patients seeking bariatric surgery as the modest weight loss in tier 3 is unlikely to meet a patient’s expectations when they seek weight reduction interventions. Although a number of studies have demonstrated that weight loss in tier 3 does not necessarily correspond to better weight loss after bariatric surgery [ 12 , 18 ], to our knowledge, there are no studies which have investigated the benefit of tier 3 services in improving surgery uptake.…”

“…Studies into tier 3 services provide conflicting reports on their effectiveness [ 11 ]. Weight loss during this period does not reliably equate to improved weight loss after surgery [ 12 ].…”

Cost-effectiveness of bariatric surgery versus community weight management to treat obesity-related idiopathic intracranial hypertension: evidence from a single-payer healthcare system

“…Although there is evidence for the cost-effectiveness of bariatric surgery and despite multiple guidelines for treatment, including from NICE [17], access to bariatric surgery within the English healthcare service remains limited, with less than .002% of the potentially eligible adults having surgery annually [27]. This is due to barriers for referral from primary care and funding constraints from the commissioners [27]. This economic model demonstrates that improving access to bariatric surgery is likely to be cost saving, reduce the burden of IIH in women with BMIs 35 kg/m 2 , and improve patient HRQoL.…”

The Health Economic Evaluation of Bariatric Surgery Versus a Community Weight Management Intervention Analysis from the Idiopathic Intracranial Hypertension Weight Trial (IIH:WT)

“…Bariatric surgery has been shown to be cost-effective [26], however access to bariatric surgery within the UK health care system, the National Health Service, remains limited with less than 0.002% of the potentially eligible adults having the surgery annually [27]. The data in this study and the original randomised control trial [18] suggest that improved access to bariatric surgery for women with active IIH with a body mass index ≥35 kg/m 2 is likely to be cost effective, with improved savings over the longer term.…”