Public Bariatric Surgery: A National Framework

Obesity is a chronic progressive disease that leads to physical, psychological, and metabolic health problems. The prevalence of obesity is increasing across the globe and in 2017-18 Australia ranked fifth among OECD countries with over one third (31%) of Australian adults living with obesity (1 p. 1). Despite this increasing prevalence, access to the full suite of effective treatments is limited in Australia, including access to bariatric-metabolic surgery Bariatric-metabolic surgery (also referred to as bariatric surgery) is a well-established, safe and effective form of obesity treatment with demonstrable meaningful and sustained weight loss over the medium to long term. Bariatric surgery has also been shown to be highly effective in reversing or improving obesity-related risks and complications in patients, especially for type 2 diabetes (2). Research evidence is consistent in supporting the cost-effectiveness of surgery in the treatment of obesity and its complication (3). Although bariatric-metabolic surgery (bariatric surgery) is one of the most effective methods for treatment of obesity, there remain barriers to access especially in the public hospital setting and access remain inadequate. Over 90% of all bariatric surgery is currently performed in the private system as access to the public hospital system remains poor, even for those with the greatest need (4 p. 5). In 2015-16 only 950 of approximately 24,000 bariatric surgeries performed in Australia occurred in public hospitals (5). A recent (2017) study suggested only 15 public hospitals from a potential 700 institutions nation-wide formally offered a bariatric-metabolic surgical programme (6). In 2019 the National Bariatric Registry recorded 22 public hospitals with bariatric cases but only 10 of these with significant (>75 per year) case load (7). This inequity of access to care is concerning. With appropriate considerations, making bariatric surgery available within the public hospital setting can provide life-changing health and wellbeing benefits to those who need it most. Further, there is increasing recognition of bariatric surgery as an early treatment option in the care of diabetes (and other chronic diseases) in both international and emerging Australian-developed guidelines (8). This is becoming the new “standard of care” for such diseases. Australian public hospitals have the opportunity to meet this standard of care through increased provision of bariatric surgery. The 2017 Public Bariatric Surgery ANZMOSS1 Summit identified that a National Framework was required to provide clear guidelines to health policy makers, clinical governance boards and health practitioners to enable: facilitation of successful implementation of bariatric surgery more widely in Australia’s public hospital system; standardisation of key care elements such as patient eligibility and prioritisation; a reduction in variations in preoperative and postoperative care pathways; development of a sustainable model of care integrated with multimodal treatment of obesity. This National Framework is the result of expert consensus from the ANZMOSS and Collective Public Bariatric Surgery Taskforce (the Taskforce), involving and endorsed by key stakeholder organisations in the treatment of obesity and bariatric surgery (see Taskforce members and participating organisations in Appendix A). The National Framework has been designed to deliver: efficient patient centred care; sustainable use of resources to cater to the disease burden of obesity in the community; deliver surgical care to the most appropriate patient populations. This Framework is complementary to the first National Framework for Clinical Obesity Services in Australia (9), developed by NACOS – a collaborative group of concerned health care professionals, which offers practical guidance on best design, delivery, and access to clinical obesity (or ‘weight management’) services in our health system. It is intended that as these frameworks go forward, surgical pathways of care as outlined in this framework and nationwide obesity services pathways and standards, as developed in the NACOS Framework, will be integrated further. Currently, this National Framework does not include considerations for children and adolescents who may need bariatric services. Additional considerations and guidelines will be developed for paediatric and adolescent bariatric surgery at a later stage