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INSIDE THE ETHICS COMMITTEE

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Programme no. 3 - Obesity Surgery

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RADIO 4

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TX DATE:听听听听听听听听听听听听听听听听听听听听听听听听听听听听TUESDAY 3RD AUGUST 2010听 0900-0945听听听听听听听听听听听

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PRESENTER:听听听听听听听听听听听听听听听听听听听听听听JOAN BAKEWELL

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CONTRIBUTORS:听听听听听听听听听听听听听听 NICK FINER

听听听听听听听听听听听听听听听听听听听听听听听听听听听听听听听听听听听听听听听听听听DEBORAH BOWMAN

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PRODUCER:听听听听听听听听听听听听听听听听听听听听听听BETH EASTWOOD

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NOT CHECKED AS BROADCAST

BAKEWELL

How should a surgeon respond when an obese patient, who's paid privately for weight loss surgery, seeks NHS help when that surgery has unexpected consequences?

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Welcome to Inside the Ethics Committee.

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The UK's obesity epidemic is out of control.听 Today about a quarter of adults are classified as obese.听 More and more patients want weight-loss surgery. Healthcare professionals struggle to meet their needs.

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We consider the case of a surgeon who runs a weight loss service within an NHS trust, and the dilemmas he had to confront.

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SURGEON

When this service first started we were just dealing with very small numbers of patients but this has increased significantly over the last couple of years.听 I probably get anywhere between 15-20 referrals a day.

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BAKEWELL

As the obesity epidemic took hold, the surgeon was struggling to meet the demand.

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SURGEON

In the hospital I work at we can do up to 200 procedures a year.听 Now that may sound a lot, certainly on the NHS, but it really is a drop in the ocean.

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BAKEWELL

That means choices must be made.

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NICE - the National Institute for Health and Clinical Excellence - recommends the NHS offer obesity surgery for patients who are what's called 'morbidly obese' - that's with a body mass index of 40 and above, or for those who are have a body mass index of 35-40 who also have diseases that could be improved if they lost weight.听

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Each trust will then develop it's own selection criteria.听 Surgeons, dieticians, psychologists, specialist nurses all work together making sure they operate on patients who they believe will benefit over the long term.

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SURGEON

There must be documented evidence they've tried absolutely everything over at least five years to lose weight. 听There must be no alcohol or drug dependence.听 They've got to be willing to be followed up for life.听 And they've ultimately got to be fit enough to have a general anaesthetic.听 I personally don't operate on smokers - they must stop smoking.听 But patients who do everything we ask of them - come to the assessments, show a willingness to actually make the significant changes to their eating behaviour, do some exercise, stop smoking - by doing very simple things they will lose weight and that tells me this patient is motivated.听 I want the best patients to actually go through and have the surgery because they will get the best outcomes.

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BAKEWELL

Such surgery requires a life-changing commitment from the patient.

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SURGEON

One thing we instil in all our patients the very first time they see us in the seminar is I do not have a magic wand and there are no quick fixes to your weight problem, it's hard work before, during and after but if they show me the motivation technically I will give them the best operation possible and with the support of myself and the rest of bariatric team their weight loss will be sustained for the rest of their life.

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BAKEWELL

At the age of 33 Kerry was 23 stone.听 She tried loads of diets and they'd failed,听 and at the diet clubs she'd picked up the fact that it was a very long and tiresome matter trying to qualify for an NHS operation.听 She was put off the whole idea.听

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But her partner Paul had recently inherited some money so Kerry went online and found a private clinic offering weight loss surgery.

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KERRY

I went to see the doctor and I had seven and a half thousand pound and he says that a by-pass would be ideal for me.听 And I asked him how much that was and he said 拢10,000, I said I haven't got that sort of money, so I ended up with a gastric band.

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BAKEWELL

It's the operation of choice for many patients as it's simpler and cheaper than other forms of weight loss surgery. The gastric band is placed, via keyhole surgery, around the top of the stomach to create a small pouch of stomach above it.听

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SURGEON

The way the operation works is three times a day of regular meal habits you take a couple of mouthfuls of solid food which sits above the band, the small pouch at the top, and because of the signals back to the brain saying that part of the stomach is stretched you feel full.

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BAKEWELL

With a band in place it's expected that Kerry will eat less and lose weight.

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But it's not that simple.听 The patient must totally reform their eating habits and that takes resolve and commitment.听 NHS treatment won't go ahead until patients are thoroughly questioned and assessed.听听 Kerry says the private clinic's decision to give her a band was made rather quickly.

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KERRY

He just checked my stomach, I got weighed and basically I was sort of like in and out of the room, I was only in the room about 10 minutes.听 Was sort of like sign here, like for the money and that was it.

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BAKEWELL

Kerry had her gastric band fitted by keyhole surgery just two weeks after that consultation in the autumn of 2007.听

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All was well to begin with - she started losing weight - but then she began to feel the urge to eat more.听 As is normal after a gastric band fitting she went back to the clinic for what's called a 'band fill' which further restricts the size of the stomach pouch.

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Weight began to drop off. Kerry went for another fill at the clinic, then another.听 She lost around six stone in just under a year. But by the summer of 2008 things started to go wrong.听 Kerry began to feel sick a good deal of the time.听

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KERRY

I just wasn't able to keep food down.听 It was like I was having something to eat and then half an hour later I was going to the toilet or being sick.

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BAKEWELL

About a month later Kerry received a letter saying that the one year aftercare with the private clinic had run out. Aftercare is essential for patients with gastric bands - the NHS surgeon explains.

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SURGEON

Patients are followed up regularly to make sure that 1. they've got good weight loss; 2. that the band is actually filled adequately so they have a sense of restriction but 3. to make sure the band isn't too tight.

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BAKEWELL

Kerry's partner was worried.

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PAUL

Weeks went by, I thought this is not supposed to happen this way, she sort of gone grey in the face, for a person who was outgoing she couldn't be bothered to do anything and that isn't her.

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KERRY

I was losing really like loads of weight by this time.听 And I just felt weaker and weaker and I just didn't have no one to turn to, I just didn't know what to do.听 And I was like getting myself all worried and I didn't have anymore money to pay for more aftercare.

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BAKEWELL

With no money left Kerry couldn't return to the private clinic.听 More time went by - she was getting weaker and weaker - Paul was starting to get seriously alarmed.

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PAUL

I was running about busy obviously the housework, shopping, whatever.听 When she was getting up she was dropping my daughter off at school, coming back and just sitting on the settee and going to sleep, like she was just totally the opposite person, she was like a frail old woman like someone you would see in an old people's home.听 Didn't even have the strength to lift the cup up proper.听 She was grey looking and she was just a bag of bones.

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SURGEON

From my experience and a history like that patients not keeping any foodstuffs down whatsoever, that is an urgency.

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BAKEWELL

Kerry was struggling on.听 By the spring of this year - some 18 months after she'd first begun to feel sick - she had lost more than eight stone.听 She now weighs less than nine stone.听 But at what price?听 By now she had begun to have black outs.听 Eventually after yet another black out Paul called the ambulance.

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PAUL

She was just lying on the floor.听 I picked her up, well it was like picking a bag of - honestly she was that light.听 I went and phoned an ambulance, phoned an ambulance, because [indistinct words] and I was saying can you hear us and she was just like - there was nothing in her eyes.听 I actually had to slap her across her face to bring her round.听 She went don't get - don't get the ambulance.听 I went - got to!

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BAKEWELL

She arrived at the hospital and was seen by the surgeon:

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SURGEON

Taking a history and listening to her husband she'd been blacking out at home, wasn't tolerating any fluid, wasn't tolerating any food.听 She was not in a good shape.听 So the first thing we really needed to do was to get some fluids into her as quickly as possible and we gave her oxygen as well.听 And then we arranged appropriate x-rays.

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BAKEWELL

The x-rays revealed that the band had slipped down.听 The band 'fill' had been too tight causing the months of vomiting which in turn had caused the slippage.

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SURGEON

We had to take the band out to basically allow her stomach to do what a stomach could do, which was to actually hold fluid and drink.听 And there's always a risk that the band could either erode into the stomach or that she could lose the blood supply to the top part of her stomach because the band being so tight and it could even mean a complete removal of her stomach.听 And given that this lady was malnurished there's far more complications because of that.

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KELLY

The doctor came to see us and explained like the band had slipped and it had had to be removed but I didn't want it removed.

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DOCTOR

It's a common thing we see that people have spent a lot of money and they've put all their hope into this operation to lose weight and certainy with numbers this lady had lost weight but potentially she has a life threatening emergency.

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KELLY

Having the band in I just thought oh like it was for life because nobody told us the risks and I just thought it was for life and I'd be thin always.

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BAKEWELL

Kerry's story is not unusual.听 Given the scale of Britain's obesity problem many people are seeking what they think of as a quick fix of weight loss surgery at a private clinic.

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Then when things go wrong they turn up at A&E departments asking NHS surgeons to help them out.

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SURGEON

Technically it's straightforward to put a gastric band inside somebody.听 However, it's not all about the surgery.听 A common theme that I've seen with patients who've been operated on elsewhere is they really didn't understand their operations, they really didn't understand what could go wrong, they're not being followed up and that leads to patients on a regular basis ending up in their accident and emergency departments and there's going to be more and more of it.

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BAKEWELL

Now lets hear what our panel of experts has to say.

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They are:听 Professor Nick Finer who runs the weight loss service at University College Hospitals London and has developed multidisciplinary teams for obesity care in several UK hospitals.听 Deborah Bowman,听 senior lecturer in ethics and law at听 St Georges University of London. And Mark Sheehan, ethics research fellow at Oxford Biomedical Research Centre, who sits on the Priorities Forum for a South Central strategy health authority.

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Well we are all entitled to healthcare, surely Deborah Bowman?

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BOWMAN

Yes that's the normal position.听 There are several things about what care means though and what we expect from patients, if anything, and whether that changes depending on where they receive their initial care.

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BAKEWELL

Professor Finer, is it the case that individuals have a moral responsibility for their own health to some extent, for not getting so critically ill?

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FINER

Yes I think patients do have an obligation to not only look after themselves but to work with their carers to try and optimise their health and the healthcare that they've had access to.听 The problem I think in this particular case is that that care and the requirements from the patient are really quite complex and it is not appropriate to assume that a patient on their own is going to be able to achieve that.

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BAKEWELL

Mark Sheehan, what do you feel about this obligation for the health service but also perhaps the individual obligation?

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SHEEHAN

I think the difficulty here comes with although there's an obligation on the part of individuals to look after their own health it's a hard one to enforce.听 The other thing that's quite striking about the obesity case because of the stigma associated with obesity.听 To think about another kind of case that we don't have the same attitudes to like skiing or other sorts of dangerous sports and yet we don't seem to have the same problems in treating them when they come to an emergency room as we might in this case.

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BAKEWELL

Deborah.

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BOWMAN

I think that's a really important point.听 And actually one might argue that to ski is more of a choice than perhaps the food one eats, given that we know so much about socioeconomic influences.

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BAKEWELL

NICE has said that all morbidly obese people should be treated by the NHS but trusts can't be forced to do that can they?

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FINER

Well this is an interesting point.听 Originally there was what was called a health technology assessment performed about 2004 and this recommended and showed that this sort of treatment was cost effective.听 Normally health technology assessments - it's mandatory for those to be provided.听 In this particular case because the surgeons weren't there NICE said that it didn't have to be implemented within six months.听 Of course up and down the country strategic health authorities who were responsible for commissioning bariatric surgery took this as a green light - they didn't have to do anything.听 Two years later when the NICE clinical guidelines came out they - if you like - replaced the health technology assessment and guidelines are only advisory.听 So obesity has really suffered - if you like - from the stigma, even in terms of commissioning healthcare.

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BAKEWELL

Mark Sheehan, what do you make of this dilemma for the NHS in general?听 How can they provide enough resources?

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SHEEHAN

The trouble is that there aren't enough resources so there needs to be decisions made and some of those ones are going to be hard ones unfortunately.

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BAKEWELL

But these are very discriminatory decisions aren't they because aren't they judging people's lifestyles?

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SHEEHAN

That's where it becomes a bit sticky I think.听 Do you avoid the controversy if the criteria are sufficiently separated from the lifestyle issues?

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BAKEWELL

Nick Finer, it does mean that there is a place for private provision isn't there?

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FINER

As somebody who's worked exclusively in the health service I would love it if we didn't have to have a private sector. The problem, I think, is what is the contract of care that exists when a patient goes to see a private doctor?听 If it's to have your bunion fixed, you can argue that's very clear cut what's going to happen and what's needed.听 For something like obesity surgery that contract has to be a longer term contract because othewise it's an unfair contract and I would argue that the patient cannot truly be giving informed consent to an operation if they haven't understood that they need and would have to be able to pay lifelong care.

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BAKEWELL

Kerry did have a year's aftercare and then the money ran out and her contract was up, is that ...?

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FINER

But a year is nothing in the lifetime of somebody who's had this type of surgery.听 I mean you would be talking at the least of five, 10, 15 year follow up with active management.

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BAKEWELL

How can the NHS afford 15 years of follow up?

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FINER

I would argue how can it afford not to treat such patients?听 We know that they are costing the health service already vast amounts of money in terms of management of the diseases that they are likely to have with their severe obesity - diabetes, sleep disturbances requiring machines to keep them breathing at night - let alone the social costs of care that many such patients need.听 What NICE did was to look at the economics and showed that actually within about three years you'll recoup the cost of the surgery.听 Now there are very few things the heatlh service does where it gets its money back within three years.

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BAKEWELL

Mark Sheehan, what do you make of that?

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SHEEHAN

I think that's one of the strong cases for the obesity surgery, is exactly the cost effectiveness case.听 One of the things that's striking to me about the case is the problem of private care - the overall cost to the society doesn't disappear, even if private care was much more tightly regulated to provide the necessary after care that would just push the costs up and make it unaffordable for the people who can now afford it.听 So it wouldn't actually solve the problem, albeit making it safer, the burden would still come back on the NHS.听 That case shows something important about how we can't get away from the resource allocation problems.

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BAKEWELL

That clearly is at the heart of the problem, Deborah Bowman, but there is also the other one any child can see which is jumping a queue is not done.

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BOWMAN

But is that a moral issue or an issue of courtesy and etiquette?听 I mean I think A&E departments exist for people to, if you like, jump queues.听 I mean we have a health system that we tolerate its imperfections and one of its imperfections is that clinical need changes and people will do things that propel them to the front of a queue - whether it's fall off a bike or have surgery that goes wrong in another sector.

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BAKEWELL

Nick.

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There is a broader issue - you could argue that by having the operation done privately she has saved that cost from the NHS and all she's asking for is ongoing care.听 Now I think that's what makes this a very difficult issue and it's a problem that we're faced with all the time because it's not quite that straightforward.听 I think unlike other areas of medicine or surgery where a surgeon goes in to put right something that's gone wrong, what the surgeon's actually doing in these types of operation is altering the way your gut and your stomach work for the benefit not just of losing weight but for the effect on other diseases.听 So they're not putting something right, you could argue they're putting something wrong and that's why these people need such careful long term follow up.

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BAKEWELL

There's another element to this particular story which worries me, which is what is an ethics committee doing deciding financial priorities Nick?

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FINER

You could argue that the priorities setting committee who make these soloman's judgements are sitting in the role almost of an ethics committee.听 I have to say that my experience over many years of trying to present cases of patients to different priority setting committees is that they are ill equipped, ill informed, have prejudices but I would accept behind all that they have the difficulty of trying to balance their books.

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BAKEWELL

Now Mark, you sit on an ethics committee, so how do you feel about that?

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SHEEHAN

I don't agree with that at all.听 I think - one of the things that's most impressive to me about the committees that I've sat on is just how broad a range of input they have and the broad base of evidence that we're presented with.听 I mean we get a full survey of all the research that's done and then around the table we cover all the bases and we make a decision based on the sorts of things that would be fair and reasonable to make a decision about those issues.

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BAKEWELL

Okay Nick I'm not going to take issue with you.

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FINER

Well no, I mean there's a huge variability between the different priority setting committees but the first thing is that up and down the country primary care trusts or specialist health authorities have set completely arbitrary rules - there are probably something like 30-40 different criteria, different from NICE, which have been applied on no evidence.听 When it comes then to appealling against that completely arbitrary decision the patient has to say that they are in some way exceptional compared to any other patient who is the same, which is a bit of a tortology, and that's how they make their case.听 The problem is that if you took this particular case we're discussing there is no evidence base against which you can say that this patient was exceptional.听 You can end up with a situation where somebody weighing 30-40 stone, who happens not to have diabetes, will not be allowed to have surgery in some parts of the country.

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BAKEWELL

Deborah, this is a minefield even for the professionals.

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BOWMAN

Yes and I think what we've just shown is why it's an ethical issue actually but there are principles of fairness and equity and consistency and transparency - all of which have a bearing on financial decision making.

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BAKEWELL

Right, Well let's go back to our surgeon now and another of his dilemmas.

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Meet Sam.听 She is 27 years old.

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SAM

I've been unhappy with my weight since probably early teens because the people around us - the things they were saying - fat, tubby, lardy, wide load - just nasty things.听 I think that led to a problem.听 After I had me children it really, really was affecting us like badly.听 I probably put about six stone on from not being pregnant until after I had my first child.

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BAKEWELL

That was in 2002.听 She had a second baby in 2004 and continued to gain weight.听 Soon she was over 13 stone.听 Being only five foot four she is classified as obese.听 Sam tried dieting, and consulted her GP. But she was finding losing weight an uphill struggle.

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SAM

After I had the children I was feeling quite low about myself really I suppose, obviously I started like different diet clubs and different diets to no avail, I even tried hypnosis - I went to a local hypnotist - but still nothing, just didn't seem to help at all.听 I'd maybe lose a little bit but then as soon as I stopped I'd just put more weight back on again, so my weight eventually crept up to about 15 stone.听 That's when I felt like I just couldn't take it anymore, I was just losing all control I suppose.

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BAKEWELL

And the rumour she heard in the diet clubs was that a weight loss operation was hard to come by on the NHS.

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SAM

I'd come to realise if you go down the NHS, good luck getting it done because there's slim to no chance of you getting it done, unless you're absolutely huge.听 But then they won't do it because you're too big and you've got to lose weight.听 But then if you lose weight there seemed to be the problem of oh well you're losing weight, you don't need the operation, carry on.听 Or if you didn't lose weight - well you're showing no commitment, we can't give you the operation.听 To get it done on the NHS, to go through all the proper channels, just seemed like such a big ordeal.

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BAKEWELL

The assessment process in the NHS is challenging for a reason.听 It's designed to make sure that people who are most likely to benefit from surgery get it and are enabled to lose weight.

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SURGEON

We want a well motivated and educated patient, so we do put a major emphasis on that before we actually operate on our patients.听 They have to start thinking about their eating patterns, about exercise.听 Most of my patients wouldn't know how to start to exercise but doing simple things to try and start getting them active.听 They get information about portion size, about making right choices as regards to what to eat and you'd be surprised how people don't understand what a good diet is still in 2010.听 And the whole process is nine to 12 weeks is to start getting patients in the right frame of mind because all these things must be in place before we operate because if they're not we put patients through a potentially dangerous operation but with no good outcome, they have very poor weight losses.

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BAKEWELL

The assessment is indeed very thorough:听 patients see a specialist nurse and a dietician. Any psychological issues they have are addressed by a psychologist, all helping to make sure that the operation will be a success.

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Sam was desperate for an operation, so she went online.听 She teamed up with a friend who also had weight problems.听 Together they found a clinic in Belgium which was offering a bargain - two ops for the price of one.

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SAM

At the time it was about 7,000 here but you could get both done at the same price abroad or even a bit cheaper I think it was, and that was including your hotel, your flights and someone to bring you from the hospital to the airport, backwards and forwards and things there as well.听 So she decided that she would have it done as well.听 It was really as simple as that.

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BAKEWELL

Sam's dad had come into a bit of money, so she booked an appointment. A couple of weeks later, she and her friend embarked on their health tourism adventure together. The assessments they were given were far briefer than any NHS investigation.

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SAM

When we got over to Belgium we got weighed, measured, talked to the dietician and then we had our meeting with the surgeon. 听Thinking about it now it probably wasn't the best because there was two of us we both had our consultation together.听 He asked us obviously which procedure we wanted to go for - the gastric band or the gastric by-pass - we both chose the band.听 We then back to the hotel and the surgeon had said right have your last meal tonight - a small one - which obviously we didn't - we went out and we had the last supper type thing, everone that has a band or a by-pass will usually say oh we're having our last supper.听 And then the next morning - eight o'clock in the morning - we went back to the hospital.

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BAKEWELL

Sam and her friend both had their bands fitted by keyhole surgery.

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After convalescing in the hotel they flew home.听 A couple of months after the operation Sam found she was eating more and needed a band 'fill' to provide more restriction.听

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SAM

When we were abroad the doctor said oh yes you can come back over and have fills.听 Well I suppose even at the time we knew realistically we were never going to go back over because we wouldn't be able to afford it.听 This was a one off pot of money I suppose that we had to get the operation done and we weren't going to be able to afford to keep going back - the flights, the hotels and everything.

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BAKEWELL

Sam and her friend shopped around and found a private clinic in the UK.听 She paid 拢250 to have her band filled.听 And then she had no more cash.听 So she got referred to the surgeon in this story and he provided more fills on the NHS.听 Sam lost a couple of stone but she found the eating pattern - small amounts at each meal -听 really difficult.

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SURGEON

I saw Sam several times and initially her weight loss was okay but it became evident very quickly that she had great difficulty in coping with the fact that she was restricted in the volume of food that she could eat - that is how the band works.

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SAM

As a family we used to go out for a lot of meals together, like rather than going down the pub or having parties or anything our family thing would be to have meals together.听 I used to obviously eat too much at those meals but now it was getting where obviously you could enjoy the conversation and things, you just felt you were missing out on something, it was more of a dread going to them than anything else.

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BAKEWELL

And Sam was failing to lose weight.

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SAM

I was finding it really, really difficult to eat anything that I was supposed to be eating like chicken, fish or vegetables.

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BAKEWELL

These foods are recommended because they are nutritious and, being fibrous, they stay in the small stomach pouch above the band for longer triggering a feeling of fullness.

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But this was an enormous lifestyle leap for Sam.听 All her life she'd been used to eating sugary fatty foods, many of which are soft and just slide past the small pouch of stomach, through the band, into the rest of the stomach below.听

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SURGEON

Things like chocolate, boiled sweets, milk, ice cream will easily get through the band very quickly and you're not getting any feedback to the brain to say you feel full.

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SAM

The foods that I had a liking for, even things that you wouldn't realise like pies, because the pastry's full of fat, it would slide down easier.听 So it really was like fighting a losing battle with me.

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SURGEON

For the operation to work you have to have this well motivated informed individual and she couldn't control herself with her eating.听 Such that I think over a period of a year, 18 months, we came to a decision that the gastric band was not working for her and she asked for the band to be removed.听 And that is exactly what we did.

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SAM

I felt ashamed, I felt like a failure.听 I didn't want everyone to know that, even though I had had the band put in I thought you'd be careful about what you ate but it wasn't like that, so I felt like I had failed.

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BAKEWELL

Since having her gastric band removed three years ago, Sam has regained all the weight she lost.听 She has joined the NHS waiting list for surgery.

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Cases like this pose a real dilemma for the surgeon.. When he set up the service, Sam was one of just a handful of patients who'd had an operation at a private clinic and then turned up when things went wrong, hoping for help from the NHS.听 The operations themselves are usually technically good:听 what goes wrong is the patient's ability to manage the after-effects, which in turn reflects the lack of thorough assessment before they went ahead in the first place.听听

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The surgeon is struggling against a rising obesity epidemic - more and more patients, receiving operations in the private sector, are seeking help from his NHS service.

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SURGEON

Over the years because I had capacity and we were a developing service I could see these patients but that just does not exist anymore with the sheer numbers that we are dealing with, it's just impossible, absolutely impossible.听 With emergency cases it's relatively straightforward - I see them, that is what the NHS is there for - but those patients who in the non-emergency setting who have been operated on elsewhere, they've paid good money for it, but they don't have anymore money, who's going to look after them?听 And I felt uncomfortable that this should be an additional burden to the NHS.听 And so it was a case of what were my other options and this is the case I took to our ethical committee.

听

BAKEWELL

Back to our panel now to take up those ethical dilemmas.听 Nick, this is a dilemma borne of the abundance of demand rushing towards the NHS which can't cope, so how do you set about making judgements - this is a woman who doesn't have to have surgery, she's not ailing, she doesn't got to the A&E department?

听

FINER

In any area where there is capacity that does not meet the demand one has to try and find some way of prioritising.听 I think that the priorities should be based on what is now being increasingly called patients with severe or complex obesity, in other words they have something more than just excess weight and that surgery is not a weight loss operation, it is weight loss to achieve health benefit.听 So the priority will presumably be on those patients who are most likely to get the most benefit.

听

BAKEWELL

And what sort of thing would qualify them for an operation?

听

FINER

Things like diabetes - 80% of which is related to obesity and about 70% of people with diabetes go into remission after surgery.听 Sleep apnoea, where you stop breathing at night, a very major cause of road traffic accidents, treated usually with a breathing machine at night, that will remit after surgery.听 There is increasing concern over liver disease with cirrhosis and even liver cancer developing.听 The list is very, very long.听 But the dilemma is do you operate early before these things develop or do you wait until they develop and then say now you've got severe and complex obesity you can have your operation?

听

BAKEWELL

Now Mark, you sit on just such a committee making these ethical decisions, what ethical criteria do you bring to bear?

听

SHEEHAN

The sorts of things that we take into consideration are evidence of clinical effectiveness and cost effectiveness, equity - that is thinking about the ways in which individual people who need the NHS are treated - things like healthcare need and capacity to benefit, as well as the cost of the treatment and what sorts of other treatments aren't going to be funded if we fund this one.

听

BAKEWELL

So what happens to the people who get rejected - do they have a right of appeal?

听

SHEEHAN

In the priorities committee the decisions aren't about individuals, they're about policies that are adopted in the context of all of the other policies and all of the other treatments.听 And then once that policy is settled then individual patients can appeal and make a case for them being an exception to the policy.

听

BAKEWELL

Deborah Bowman, is there something special about obesity here because I'm mindful of the fact that women can have IVF treatment privately, pay for it, and then go to the NHS and nobody draws up these kind of rather severe clinical decisions for them?

听

BOWMAN

I think there is something distinct about obesity.听 I think there is something distinct about diseases that we believe to have a lifestyle dimension to them.听 The other obvious example is the treatment of drug addiction and alcohol dependence and all the physical sequelae of that.听 So one of the merits, if one wants to look at it like that, of a committee looking in the round is to raise a flag and say are we treating this group differently and if so why.听 Can we make a good case for difference?听 And very often I think we can't.

听

BAKEWELL

The trouble is it gives an opportunity for people's own subjective judgements to come in, I mean we all do have a world view about who deserves things.

听

FINER

In terms of hospital care we provide what is purchased now.听 So the idea that the physician or the surgeon has choice is I would argue quite limited.听 I mean the bottom line - if your surgeon operates on somebody who is not covered by the rules the hospital doesn't get paid and I can tell you that soon gets back to the surgical team. So in some ways as clinicians we are slightly removed now from making those ethical decisions.听 Back 10-15 years ago it was something we all did intuitively, probably rather badly, but at least we did it and it was done on a personal basis, rather than an impersonal basis.

听

BAKEWELL

Mark, what do you make of this?

听

SHEEHAN

I think there's two interesting things that follow up from Deborah and Nick's comments there.听 The first one is this point about the subjectivity - the judgement of the individual be it a clinician or whoever.听 I take it that this is one of the central reasons for justifying a committee or some sort of fair process whereby these decisions are made, so that you tend to avoid or at least muzzle the subjectivity of these sorts of things.听 The second point is I think I completely agree with Nick about the difficulty for the individual clinician making these decisions.听 I mean I would argue a bit more strongly than that and suggest that it's ethically not the role of the surgeon or the clinician to have to have in mind the cost to everybody else.听 One of the important parts about when you go to the doctor is that you expect the doctor to be looking after you.

听

BAKEWELL

I can see that rather alarmingly myself, I can see that ethical criteria might not prioritise the very old.

听

FINER

Absolutely.听 I mean one of the questions that one is often asked - well what would you do if it was your mother or father - and that has now become a question that is almost irrelevant.

听

SHEEHAN

The question of age is a really interesting one because I think our intuitions about it are very different.听 I mean we don't want to see the elderly left uncared for and stuff but at the same time I think we have strong intuitions about who you would prioritise.听 Various studies have shown that people tend to prioritise children aged seven over just about everybody else.

听

BAKEWELL

So we can't treat everyone but we have a huge abundance of people who are obese- who do we treat?听 How do we do that?听 Mark.

听

SHEEHAN

I think that what's important is that there's a process in place that makes these decisions and makes these decisions in the context of all of the other decisions that need to be made and that every group that needs treatment, every kind of condition and way of dealing with those conditions should be taken in the round.

听

BAKEWELL

Deborah, is this something for the public to join in?

听

BOWMAN

It's very tempting to say yes, absolutely.听 However, when this has been tried actually the public are really not that interested in making these sorts of very difficult decisions.听 The other issue I think about involving the public - it's one what ethicist memorably called the red neck factor - the idea that as a group a majority opinion may be discriminatory and if we simply go for the majority view that in itself might be problematic.

听

BAKEWELL

Nick.

听

FINER

I am unconvinced that these priority setting committees are responsive enough to the rapidly changing evidence base we have.听 So, for example, the data on the effects of weight loss surgery on causing diabetes to go away has really only come out over the last two or three years.听 But have guidelines changed as a result of that?听 If you're talking about where would the money come from for all this extra weight loss surgery I would say very simply you can steal it from the diabetes budget because if we did it they wouldn't need it.

听

BAKEWELL

Mark, you were about to comment?

听

SHEEHAN

I certainly don't think that the system of priorities committees is perfect.听 One of the things that does strike me as very important, which I think these committees could work on, is being a bit more public about it.

听

BAKEWELL

Right, well it is accessible now, so it's time for you to decide what would each of you advise the surgeon.听 Nick Finer.

听

FINER

I think that he has to concentrate on those patients that he has assessed and that he has treated and that means that the patients who have gone outside of the NHS will have to, if you like, take their own chances.听 At the same time he clearly needs to drive an expansion of his resources so that firstly patients aren't tempted to go outside and secondly maybe there should be a service provided and paid for for these patients.听 But somebody has to recognise that there is this group of patients who at the moment are not covered by any process.

听

BAKEWELL

Deborah Bowman.

听

BOWMAN

I would suggest that he directs his very understandable frustration into talking to those who do make these decisions and really being very honest and transparent about what he's experiencing.听 And if it's decided that this is how we're going to muddle through with this situation that should be said, it should be consciously stated rather than simply allowed to happen by default.

听

BAKEWELL

Mark Sheehan.

听

SHEEHAN

What would be most useful for him would be to start thinking about the kinds of care differences that might help him to prioritise the various different patients, irrespective of whether they've paid for the treatment on the NHS or not.听 So if he could come up with some sort of general set of criteria, perhaps somebody who had had a surgery privately that had gone horribly wrong should presumably be treated immediately, whereas somebody, as in the second case perhaps, where there was issues about her commitment to the lifestyle - towards the lifestyle changes that were needed - would perhaps enter in at the same level as any other NHS patient who had questions about their lifestyle.

听

BAKEWELL

Thank you.

听

So lets hear how our surgeon resolved his ethical dilemma - what choices he made.

听

SURGEON

When they come with a non-urgent problem, number one they really should contact the company or the surgeon that did their original operation.听 The second one is:听 if they are prepared to go privately locally they should do that.听 The third option is that I will ask the GP to write to the primary care trust asking for funding on a named patient basis to be made available for this patient to be looked after on the NHS.听 And currently that's what we do.

听

BAKEWELL

There remain the听 people who can't afford to pay for further treatment听 for听 the problems they are having.听 They must wait to see whether their primary care trust will fund their care.

听

SURGEON

We are just waiting to hear from a primary care trust but my great fear is, in the current economic climate that we are all in, I do not know if primary care trusts are going to be able to pay for these patients who have been looked after elsewhere and it's a great fear and I'm not sure what's going to happen.听 My guide for now is that if I think there is a risk to this patient's health by me not intervening then I will get them out of trouble but then that's my only input to these patients.听 For patients who want a fill, if I don't think their weight is decreasing, there's not such a risk and those I can't do much about on the NHS.

听

BAKEWELL

Both Sam and Kerry are back to square one - thousands of pounds out of pocket, and once again putting on weight. Only if they make it through the assessment process this autumn will they be eligible for another operation that this time might help them overcome their weight problems.

听

Since the spring, Kerry has already put three stone back on.

听

KERRY

I don't want to put any more weight on that's the thing, I don't want to be massive like again, just like out of breath and just can't be bothered to do anything when you're overweight.听 People are looking at you in the street and sly comments.听 I have asked the doctor for a by-pass but I'll have to wait and see.

听

SAM

My plan for the future now is hopefully see the psychologist, whatever has messed up my head, help me unjumble it all and get some - get to grips with whatever it is that's off a little bit and hopefully I'll get my eating habits back in touch.

听

ENDS