Number one

Monitoring a patient after bariatric surgery abroad

The scene

A GP contacted the MDU after a patient requested he carry out post-operative monitoring after having bariatric surgery abroad.

The patient brought a letter with instructions from the surgeon, but the GP explained that they didn't feel they had the expertise to interpret these tests in the context of complex weight-loss surgery.

The patient explained that the surgeon had agreed to advise the GP as necessary on any abnormalities, and that if the surgery had occurred on the NHS, the GP would be required to do this monitoring in the long term anyway. The GP asked the MDU for advice on what to do.

Background

Obesity is on the rise and remains a major health and economic concern for the NHS. Given that bariatric surgery is recognised as an appropriate and cost-effective treatment for people with severe and complex obesity, the demand for such procedures is likely to increase in the context of an already stretched health service.

There are strict criteria⁷ for those who qualify for these NHS interventions and the cost of private equivalents can range from around £4,000 to £15,000 depending on the procedure. The same procedures overseas are being advertised at around £3,000, which explains why some patients take this option. It does, however, leave UK clinicians in a difficult position when patients return and request monitoring by their NHS GP.

Appropriate follow-up care after bariatric surgery is vital to maximise the chance of a safe and successful outcome.

NICE's Overweight and obesity management standard⁸ recognises these risks and specifies that people who have had bariatric surgery should be offered a follow-up care package for a minimum of two years within the bariatric service. Thereafter, ‘adults discharged from the bariatric surgery service have follow up at least annually, as part of a shared-care model between specialist weight management services and primary care.’

The British Obesity and Metabolic Surgery Society (BOMSS) has released a statement on medical tourism abroad⁹ which advises the need for specialist follow up by a specialist team for the first two years post-operatively, followed by lifelong annual reviews.

They have also released post-bariatric surgery nutritional guidance for GPs¹⁰ which recognises that this publication does not replace obtaining clinical support and advice from a bariatric surgery unit. It also flags that GPs should take caution when patients have had surgery abroad as the procedures may differ from those performed in the UK.

MDU advice

The MDU adviser discussed the case with the GP in the context of these guidelines for NHS patients.

They state that patients require specialist bariatric MDT follow up for the first two years post-operatively and that GP follow-up will be within a shared care arrangement. While the patient in question had surgery overseas, the need for support and monitoring remains regardless of where the surgery was done.

The GMC's Good medical practice¹¹ is also clear that, 'You must recognise and work within the limits of your competence.'

Although the patient offered assurances that their overseas surgeon is happy to give advice, a UK-based GP would leave themselves open to criticism by relying on advice from a specialist based overseas. As the provider is based in another country, they are not subject to the same regulatory requirements as doctors in the UK and work to different guidelines. There might also be language barriers that would make shared care inappropriate and unsafe.

Taking the above points into account, a GP without the support of a UK-based bariatric specialist could struggle to justify why they took on monitoring for a complex patient if something went wrong.

The outcome

The MDU adviser suggested the GP liaise with their ICB and bariatric services to see if they would take over the specialist follow-up for this patient, even though the surgery was not performed in their unit. This would mean the GP could access local, specialist advice, such as whether to organise blood tests and advice on any problems encountered in the patient's general care.

Private/NHS interface

Patients entitled to NHS treatment can switch from private treatment to NHS care as long as that treatment is supported by the NHS. However, many patients who opt for surgery abroad do so because they don't meet the criteria for bariatric surgery funded by the NHS, meaning they may not qualify for NHS funded bariatric follow-up care.

It's advisable for GPs in this situation to check what the situation is with their ICB. It would also be appropriate to ask the ICB to confirm their decisions in writing, so that if the patient is advised to self-fund private follow-up, the GP can demonstrate that they did explore the options for NHS care.

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