BOMSS Standards for Clinical Services and Commissioning Guidelines
PROVIDING BARIATRIC SURGERY
BOMSS Standards for Clinical Services & Guidance on Commissioning
for and on behalf of BOMSS Council, October 2012
BOMSS Service Standards and Commissioning Advisory Working Party:
|Alberic Fiennes||Chandra Cheruvu||Sally Norton|
|Shaw Somers||Pratik Sufi||Mike Lander (SEC SCG)|
|Peter Small||Shamsi El Hasani||Brian Dobbins|
|Mary O’Kane||Keith Seymour||Ian Beckingham|
Established Severe Obesity is disease state, for which bariatric surgery is the only current clinically effective and cost-effective treatment.
BOMSS recognises existing national and international guidelines as the outline principles of good practice. The present Standards are intended to support translation of these principles into practical service and quality structures for the UK.
Good practice evolves, so the present standards remain work-in-progress and represent a consensus gathered at the time of writing. The full text available for download below should be consulted.
Senior professionals in each bariatric team must satisfy themselves and their Clinical Governance Lead that their practice and service meet the existing published standards.
Bariatric care should be safe, kind, based on recognised best practice, effective and cost-effective.
Patients should be treated in an appropriate facility by the appropriate clinicians.
BOMSS recognises the concept of Metabolic Surgery, but deprecates the promotion, marketing and provision of bariatric procedures with primarily cosmetic intent and/or at inappropriately low BMI.
The exact application of guidance may differ between NHS units, commercial providers in the independent sector and private provision by free-standing clinician groups, but BOMSS recommends that the following be upheld in all bariatric service provision.
CORE REQUIREMENTS FOR A BARIATRIC SERVICE
1. PURPOSE OF A BARIATRIC SERVICE
Any safe and reasonable bariatric care pathway service should comprise:
- assessment of patient suitability and of treatment needs.
- structured and documented information giving,
- patient preparation, personal and clinical.
- technically competent surgical treatment, transparently and appropriately chosen.
- post-operative support for patients in making adjustments to their lives after surgery.
- safe and continued clinical follow-up: provision of surgery without that commitment is deplored.
2. GENERAL SERVICE STRUCTURE:
Service delivery should be through a multidisciplinary and multi-professional team (MDT process).
The core MDT should at least comprise:
- Specialist Bariatric Surgeon(s)
- Bariatric Nurse Specialist(s)
- Specialist Bariatric Dietitian(s)
There should be standing and immediate access to specialist physicians, psychologist or psychiatrist and senior anaesthetists , all with experience of bariatric patients’ needs. Standing referral pathways are also needed to wider support disciplines
The MDT should be led by a bariatric surgeon. It may have links to a medical obesity service, but BOMSS does not recommend a structure that reduces the surgical team to technician status.
A bariatric service should be able to undertake a reproducible, comprehensive multidisciplinary needs- and risk assessment, including:
- stringent physiological scrutiny of super-obese and super-super-obese patients
- screening for Eating Disorders and psychological morbidity.
- consideration of the most suitable procedure, including its potential risk profile.
Support and Counselling
A bariatric service must offer education, guidance and motivational support throughout treatment .
Professional personnel working with the team must meet BOMSS Professional Standards. All personnel at provider institutions must recognise the sensitivities of bariatric surgery patients.
Facilities at which bariatric surgery is undertaken must meet BOMSS Professional Standards, in part re-iterated in the present full text. The development of networks may support facility needs.
Bariatric surgery should only be undertaken in facilities that are adequately equipped.
Operating theatres must able to support safe surgery, including emergency re-operating.
Bariatric patients must have access to appropriate levels of recovery and critical care support.
Patients should receive bariatric care on a standardised pathway, under protocols addressing
- referral guidelines and the management of funding ,
- self-referral issues and primary care liaison
- inappropriately rapid process
- working roles and competencies of team members
- governance, risk management and risk responsibility to ensure that patients are operated on within the competence of the surgeon and team
6. INFORMATION & CONSENT
Along the treatment pathway patients must be given information that enables them to give genuine consent to the treatment pathway and to the surgery.
Two important components must be provided for in the follow-up care of bariatric surgery patients:
- The care of post-operative complications and delayed emergencies.
- Continuous clinical follow up to support clinical outcome, micronutrition and patient needs
Lack of any surgical or surgeon-led consultations over the ensuing period is deplorable.
BOMSS advises professionals participating in such processes to consider whether they are placing themselves in professional jeopardy.
BOMSS advises strongly against the commissioning of services within the NHS that omit or seek to limit the period of follow-up in Secondary Care.
BOMSS is committed to national audit through the National Bariatric Surgery Registry.
9. KEY QUALITY INDICATORS
The present guidelines consider which outcome indicators are appropriate and which may be less so. The focus should be on comorbidity resolution, rehabilitation and well-being, not just weight loss.
10. SERVICE INTEGRITY
Achieving the preceding standards implies that a Service must have “critical mass”, so that new services may be best developed within a network. Independent sector providers and private practice clinician groups will need their own mechanisms for emulating these minima.
In many instances high quality service is currently provided by very experienced individuals and teams with lower volumes and personnel establishment than is recommended for the future. The full guidance must not be interpreted to disestablish or weaken these excellent services.
BOMSS recommends that future Services within the NHS be structured by analogy to cancer services around Bariatric Units and Bariatric Centres, integrated within a Bariatric Network. The full guidance sets out benchmarks for units and for centres in relation to:
- Service volume
- Surgical and AHP personnel
- Case-mix and competency
2. COMPETENCE OF SERVICE
Patients may occasionally need to be advised that a given Unit is not the appropriate setting for their treatment and that they may need to be treated at a Centre. Commissioners must support that allocation.
3. ACCESS TO SERVICE
BOMSS recognises the suitability criteria for bariatric surgery set out in NICE CG43 as well founded, fair and evidence based, and as peer supported in IFSO, NIH, ASMBS and SIGN guidance.
BOMSS recognises the resource constraints faced by NHS commissioners. Any strategy for targeting resource appropriately should be
- within these guidelines
- fair and equitable
- evidence based
- aimed at best use of resources
4. APPLICABILITY TO INDEPENDENT SERVICE PROVIDERS
The standards determining the viability, safety and integrity of service by independent and commercial providers of bariatric surgery should be no different in principle.
5. PROVIDING TO INDIVIDUAL PATIENTS IN PRIVATE PRACTICE
Applicability of Service Standards
It is the view of BOMSS that private clinical groups providing bariatric surgery to individual self-funding (or rarely insurance-funded) patients should at all times at least meet the standards for NHS services. Surgeons will need to avoid involvement in processes that are not of comparable quality.
BOMSS requires that a joint interest between clinician and patient on health-improvement be the primary focus at all times and deprecates the exploitation of vulnerable people
Download the full service standards, specimen consent form and safety card below: