18 DECEMBER 2003

DR IAN CAMPBELL, DR COLIN WAINE, DR NICK FINER, PROFESSOR JOHN BAXTER AND MS DYMPNA PEARSON

  Q1060 Jim Dowd: When the Committee was in New York we saw a bariatric surgeon there, who went through the procedures in some details. It did not mean that much to those of us who are not doctors, but when we put to him that when stapling the stomach, all he is doing there is reducing the capacity of the body to process food at any time, he said that the factor of doing it reduced a pepto or peptide hormone that causes people to eat too much. They did not know the connection between reducing the capacity of the stomach and the reduction of this substance. Given that bariatric surgery is deeply invasive and, as you said, a technically complicated process, and as regards support, why is more work not going in to find the function of this particular hormone?

  Professor Baxter: There is a lot of research going on, but not as much as there should be, because it is not a fashionable area for research—at least the basic patho-physiological processes after surgery. I know what the surgeon was driving at—probably ghrelin—but every week a new hormone is discovered that might have some relationship with satiety, whether you are full or not. In America, a few research groups are looking at this in a very systematic way, funded fully by reputable grant-awarding councils; so we are getting more information. Just recently, we launched a proposal to the MRC for a trial in this country of various forms of obesity surgery versus conservative treatment, and it was turned down. This was a very big multi-disciplinary study involving many physicians, and a big strategic team, well thought-out, which we found very disappointing. Of course, the reason is that, as you well know, the MRC looks for reasons to fail grant applications rather than pass them. Sure, there were a few minor problems with it, but there are minor problems with every piece of research. We are trying to do the research in this country as well, but it is going on around the world. I would take issue with obesity surgery being deeply invasive. Gastric banding is not very invasive at all; it does not disturb the normal anatomy. Some of the operations the surgeon in New York might have shown you would be a laparoscopic by-pass, which is a lot more invasive; but it is a lot more effective. Like any surgery done in good hands, it has extremely good results. It is all about the training and skill of the team and the support and the back-up. Mortality rates from obesity surgery are less than 1 per cent, and in fact a lot less than that in skilled hands with good selection.

  Dr Finer: Could I add something from the physician's perspective? If you take somebody with a gangrenous leg, surgery is life-saving. Clearly, as a physician, I would like to prevent that happening; and if it does happen, I would like to treat it with drugs rather than surgery. The situation in terms of morbid obesity is that we are still in the days of requiring surgeons to save the lives of our patients; but the pace of understanding of the control of energy balance is moving so rapidly, both in terms of brain mechanisms and in terms of peripheral signalling from the stomach and the intestines back to the brain, is growing very rapidly and generating huge numbers of new drug targets. I think this is another reason why we really do need to have a structure for specialist management of complex obesity, because in five or ten years' time potentially we will be faced with a number of very specific drugs—no doubt they will be very expensive—and we will need specialists who will develop and evaluate their appropriate use. The other thing that I would like to add is that we are increasingly recognising that there are genetic predispositions to the development of obesity; and it is quite clear that in such patients it may be entirely appropriate to consider interventions which, on the face of it, seem drastic or draconian, but may be the only way of coping with these individuals' genetic handicap.

  Q1061 Dr Naysmith: In some ways, I think we are skating over the surface of something quite important and interesting here. When we were in America, it is true, as Jim said, we met American surgeons and an Australian surgeon; and in both of those countries a lot more bariatric surgery goes on, as you know, Professor Baxter. The question is whether much of it is necessary. It comes down to this question of when you are looking at morbid obesity there may well be a case for instances there.; However, the Australian surgeon in particular, who was a very up-front and in-your-face kind of individual, was clearly performing operations on people who were not morbidly obese. Some were certainly obese but some of them were just overweight. There is a real question about whether that is the right thing to do. There is a suggestion that in America a number of these operations are performed because people pay for them or they are funded through insurance. There is a lot of shaking of heads and so on in the States about whether or not things are done properly in this country because it is the National Health Service and the National Health Service does not provide the money. I think there is a real question to be answered here about the place of bariatric surgery in National Health Service treatment.

  Dr Campbell: We should keep the context of bariatric surgery in its rightful place, which is at the end of medical treatment, which has failed to result in the benefits we need; and then is extremely effective and should be financed. But the emphasis surely must be on having treatment accessible to the majority of obese patients, which should be primary care based, with dietetic support, with medication, with access to specialist services and surgery, when appropriate. It is important that we do not forget that primary care has the best opportunity to deliver weight management for the majority of patients and in the most effective way.

  Ms Pearson: I would completely agree with Dr Campbell's points about primary care needing investment. The dietetic services can really lead the way within primary care, because dieticians are the best equipped profession—with four years' training on nutrition, we understand the public health and clinical remit. We have an advisory role. It is not about dieticians seeing every patient who is overweight or obese, but an advisory role at national and local level—and it is a shame that we no nutrition advisor at the Department of Health at the moment. We have a training role of all other healthcare professionals and we also had an advisory role for advising about options that are outside the NHS, which I think we increasingly need to look at, and the value of the contribution that could be made from those. We have a clinical remit as well.

  Q1062 Chairman: Professor Baxter, you have argued for increased use of the private hospitals in respect of surgery. Presumably, the bulk of the surgeons working in the private sector also work primarily in the NHS, doing the same sort of job. Have you done any analysis of what impact putting more people into the private sector would have on the NHS? Secondly, have you analysed comparative costs if the work was done in the private sector, compared to the NHS, because obviously this Committee has looked at the concordat with the private sector. I think the average is something like 40% higher cost to the private sector than the NHS.

  Professor Baxter: I just want to agree with my other two colleagues who said we have got to keep a perspective about this. Remember that surgery is at the end of the line, and it is for a sub-set of patients. In the UK and in most countries that I go around, people ruthlessly stick to international guidelines about who is eligible and who is not. There are always cowboys somewhere, and particularly, as you quite rightly say, that will be when they can line their pockets privately, who might break those rules. To me that is a disciplinary matter. With somebody doing the job properly, according to the rules, we are all agreed there should not be a problem. In this country, I am not even aware of one case being carried outside the usual rules in the time I have been in the Society. However, I am aware of patients in this country going over to France, who would not satisfy the criteria. They are having their surgery and then coming back, which of course we deprecate. You guys are looking for solutions, and in my briefing paper I have looked at how we are going to increase the activity. Clearly, it is difficult in the current NHS, given the workload we have, to do anything very quickly. The private hospital capacity is there, and in about three or four hospitals round the country they do significant numbers of private patients, according to the strict criteria, simply because these patients do not want to wait for the Health Service, because they will wait for ever. It is the same surgeons, except in one case, who operate in the National Health Service, who do those cases privately—members of our Society, working to the same high standards; so I have no problem with people working on the private side. We have not done an analysis of relative costs except to say that at least informally, from what I understand, it is difficult to cost accurately in the health service the figures being very variable, versus the figures I have seen in private—they are comparable, if anything a bit cheaper than the private; but that is up to individual hospitals to work out. What some of my members said, when they knew I was coming here, advised me to say to you that they could do a lot more work and get through the waiting lists if it could be contracted out to private, much as they would like to do it in the NHS. They see that as the only practical way to deliver it, at least in the short term, until the NHS capacity builds up such that the private side stabilises. You can never stop patients wanting things done privately, and certainly a lot of these patients do not want to wait. If you come to me, you will wait three to four years for your operation. I am not well disposed towards private practice for my NHS patients, but I find myself increasingly doing a lot of it because I feel sorry for my patients, and they are prepared to pay for it.

  Q1063 Dr Taylor: Dr Waine told us that about 75% of the population see their general practitioner in one year, and approximately 90% over a five-year period; so GPs would seem to be ideally placed at least to screen for obesity. Should one of our recommendations be—and how practical would it be—if we were to recommend that at one visit per year at least patients' weights are recorded?

  Dr Waine: That is perfectly reasonable. That is the great strength of the British system of primary care with the captive list system. It does allow opportunistic identification of people who could benefit from being put into a weight management service.

  Q1064 Dr Taylor: That would not prove too much of a workload, would it?

  Dr Campbell: To try to put this into context, my own practice is 4,500 patients, and we have identified 483 who are clinically obese. I could not start to treat all of those tomorrow, so just measuring it is one thing. You need therefore the resources to do something about it.

  Q1065 Dr Taylor: I absolutely take that point, but just to define the size of the problem—or is that something that we know already?

  Dr Campbell: I am not sure that measuring everybody's body mass index would necessarily be that productive because you need to target those who are likely to benefit from weight management. I think GPs would be up in arms if we suggested that.

  Q1066 Dr Taylor: Somebody has already mentioned the GP contract. Does it not cover this at all?

  Dr Campbell: Apparently, out of a possible 1,000 points to be gained, only three can be gained from measuring body mass index. So if there is no incentive to do it -there is a great emphasis given to diabetic management, and yet weight management should fall within that, but there is no obligation to do so. I think that has to change.

  Q1067 Chairman: Ms Pearson, you have fought your corner for dieticians very well this morning, but I wanted to ask you this. Do you think that with additional training and a different use of your profession, you could make an even bigger contribution to this issue? Secondly, some of our witnesses have argued in writing that perhaps there is a need to look at a new profession in this area, which perhaps approaches things in a different way to the individual professionals that we traditionally use. What are your thoughts on that?

  Ms Pearson: I think it is a very good point. Dieticians are already very well trained to understand obesity, and I think that now there are posts being created across the country of consultant dietician type posts, and I think these would ideally attract the highest calibre of dieticians. Within the profession there is a renewed interest in the management of obesity, and that is what Dieticians in Obesity Management are currently undertaking training of dieticians, to have them more specialised. I think that dieticians could be key people within the primary care setting to act in an advisory, training and co-ordination role. I also think that within surgery, it does not necessarily have to be the GPs. I am training GPs and other health professionals all the time, and I find that there are people within each profession who have a real passion about treating obesity, and a real interest. If we could train those people adequately to pull it into the rest of their role, that would be a valuable use of current resources.

  Q1068 Jim Dowd: You say that dieticians are adequately trained in these matters. Can I put to your medical colleagues: is it your view that doctors are well trained in these matters?

  Dr Waine: The short answer is "no". Professor Mike Lean of Glasgow has estimated and gone on record as saying such a massive problem occupies less than 5% of the medical curriculum, and yet the work of doctors after qualification is probably driven by about 60% of the related conditions of obesity.

  Q1069 Chairman: I assume your colleagues would agree broadly with that answer. I appreciate there are many other points you would want to have raised. We would very much welcome you following up, and it may be we can come back to you for more information. I apologise that it has been a very brief session, but from our point of view it has been extremely valuable.

  Dr Waine: Chairman, on behalf of my colleagues, I thank you for the opportunity of appearing. Out in the clinical world it feels a bit like being in Holland; the dykes are breached, the sea is rushing in, and we are holding a committee meeting, with great respect!