NHS post-operative support for self-funded bariatric surgery

NHS Suffolk and North East Essex ICB have received several enquiries from General Practice regarding access to NHS post-operative support for self-funded patients who have travelled abroad for bariatric surgery.

Patients do not have the automatic right to re-enter NHS care (from private care) at any time during an episode of care in this situation. Although NICE recommends specialist MDT follow up for two years following bariatric surgery this will not be routinely provided on the NHS for those patients who have self-funded their surgery abroad and responsibility remains with the bariatric centre who performed the surgery.

If you are considering seeking private treatment of any kind, you should always discuss this with your GP surgery before taking action.

Read more about the factors we would urge you to consider.

1. NICE Guideline & Quality Standard – NICE guidance applies only to services commissioned by the NHS and within the commissioned NHS bariatric service care package (and is good practice for independent sector providers regulated by CQC) so providers of bariatric services outside of the UK are out-with the NICE expected standards. The NICE guideline is clear that the described post-operative care is part of a single episode of care to be commissioned from and provided by a Tier 4 weight management service. The NICE standards cannot therefore be automatically applied outside of those circumstances. Likewise, the British Obesity and Metabolic Surgery Society (BOMSS) Guidelines on expected standards of safe clinical practice in post-operative care apply in the UK setting, and like NICE guideline, BOMSS says that the follow-up care should remain with the bariatric centre for the first two years post-op. It would not be considered appropriate or expected for a GP practice to provide or arrange any follow-up care.
2. NHS commissioning & service specification – This is detailed in NHS England 2016 guidance, Appx 9 for Obesity Surgery, and Appx 8 for Revision Surgery for Complex Obesity. Private Patients may have had their primary obesity surgery outside of NHS contracts at independent/ private providers (in Europe, or within the United Kingdom). We expect complications of treatment that are solely the consequence of a privately funded episode of care to be managed by the private provider and be privately funded. The only exception to this is when a patient is admitted under emergency care, or the complication is life threatening.
3. Provision of standalone NHS post-surgery care to a patient who has had bariatric surgery abroad is not routinely commissioned.
4. Any request for further (up to two years only) band filling and/or routine outpatient follow-up care (not associated with an acute, non-elective episode for these patients) will require the agreement of the appropriate commissioner and will need to demonstrate that the patient has met recommended eligibility criteria for obesity surgery. In order to access this, the patient, the patient’s GP and Private Provider would therefore be required to collaborate to provide evidence on:
   • Weight Management Service attendance including Tier 3
   • Recommended criteria and Guidance fulfilment
   • Primary obesity operation
   • Follow-up attendance
   • Response to primary operation
     
     If these factors are not completely fulfilled, patient would not be eligible for NHS follow up of their bariatric surgery.
     
     If these factors are fulfilled, a GP letter with accompanying evidence of fulfilment should be sent to clinical.priorities@snee.nhs.uk for prior approval. This is in line with the Clinical Guidance: Revision Surgery for Complex Obesity.
5. If these factors are not completely fulfilled but the referring clinician considers the individual demonstrates clinical exceptionality, then an exceptional clinical circumstances application should be completed and submitted to the ICB using the following email address: clinical.priorities@snee.nhs.uk.
   
   The application must include evidence of clinical exceptionality and exceptional capacity to benefit. Full details are described in the SNEE ICB Clinical Priorities Policy which can be found on our policies page.
6. Managing the boundaries between NHS and private care – SNEE ICB has a very comprehensive policy covering boundaries between NHS and Private Healthcare, based on national guidance, which can be produced on request. Please contact us if you would like to request a copy.
   
   The fact that a patient can demonstrate they have benefited from the private treatment does not necessarily provide grounds for continuing the treatment in the NHS as an exception.
   
   Whilst patients who commence care privately can request that further treatment (that would have been commissioned by SNEE ICB) be provided within the NHS, their clinical needs should be reassessed for NHS treatment within the same regime of priorities applicable to NHS patients with the same condition. A patient is not entitled to “pick and mix” elements of NHS and private care in the same treatment, and so is unable to have privately funded and NHS funded care provided as part of the same care episode – the national service specification and NICE guideline is clear that the bariatric surgery pre-, peri- and post-operative care is part of a single episode of care and should all be provided by the Tier 4 service provider multidisciplinary team.
   
   Accordingly, if a patient commences a course of treatment that the SNEE ICB would not usually fund, SNEE ICB will not pick up the costs of the patient either completing the course of treatment or receiving on-going treatment. This is regardless of whether an individual cannot afford ongoing private treatment costs, private health insurance does not cover the full cost of the treatment, or if the patient requests the NHS to pick up the cost on the grounds that the treatment is clinically effective.
7. Patient responsibilities prior to seeking surgery abroad – Government advice, NHS advice and some patient support groups’ advice on Treatment Abroad all advise that patients must be clear about how aftercare will be co-ordinated and provided after the surgery. The patient may be responsible for costs of the aftercare and of possible return trips associated with aftercare. Patients who have paid for bariatric surgery abroad have a responsibility to review and plan for all points in the recommended Treatment Abroad checklist and may choose to buy a standalone package of post-op care through a UK independent sector provider, or other non-UK provider. A leaflet has been produced for patients to explain this, and they will be encouraged to discuss with their GP before seeking treatment overseas.

In summary

• GP surgeries cannot be expected to provide specialist aftercare following treatment sought overseas or in the private sector
• The patient has a responsibility to ensure that they have understood the implications of sourcing treatment in the private sector or overseas (including assurance of the arrangements for their aftercare) before undergoing treatment.
• Specialist obesity services are not routinely commissioned.
  • Patients are only likely to be eligible for the route outlined in “4” if they had been at the point of already being on an NHS waiting list for Obesity Surgery (having completed the other steps) at the time of private treatment.
  • Patients would only be eligible for the route outlined in “5” if their clinical circumstances are exceptional, which is unlikely in the majority of circumstances.

The ICB does not maintain a list of approved private providers, but if a GP would like advice or support regarding the signposting of patients to a suitable UK private provider they would be welcome to contact the Alliance primary care team.