24 January 2024

Why NHS patients are resorting to weight-loss surgery overseas

A case involving gastric-sleeve surgery in Turkey revealed the UK’s failures in tackling obesity.

Manda was disappointed. “It’s been months since the surgery, and I’ve only lost one and a half kilos.”

“Two secs, sorry.” I turned back to the computer and rechecked her notes. But no, there had been no consultant letters, no discharge summary.

“I’m really sorry,” I said. “What surgery?”

“The weight-loss op! I got fed up. I went to Turkey.”

It had been nearly four years since I’d referred her to our local Tier 3 weight management service – the only route to access surgical treatment for obesity on the NHS. They’re overwhelmed and Manda, like so many others, had yet to receive an assessment appointment.

She filled me in. How eventually she had decided to go privately, but the cost in the UK had been prohibitive. How she had found a Turkish clinic charging a quarter of the price. How that summer she had exchanged sun lounger for hospital bed.

“What do they say about it, then?”

It was her turn to look puzzled. “I haven’t heard from them since I came home.”

Manda is sick of being obese, and demoralised by the failure of numerous diets and gym memberships to make any sustained difference. As far as she’s concerned, there are operations that can take care of it, and if a hospital abroad will do one for a couple of grand, so much the better. What she was oblivious to is the need for patients to be carefully selected for psychological suitability. Surgery must be followed by enduring lifestyle changes if it is to be successful. Then there’s the two years of aftercare, both to help sustain progress and to monitor for the nutritional deficiencies that frequently follow surgery. No wonder she got such a bargain: her Turkish package had provided none of that.

There are various types of operation with different potential complications: some reduce stomach size so less can be eaten, others replumb the intestines so food bypasses much of the gut. Manda didn’t know which she’d had. I asked her to drop the paperwork round. Medical terminology proved surprisingly similar in Turkish so I was able to piece things together. She’d had a gastric sleeve – where a large part of the stomach is excised, leaving behind just a narrowed tube.

Obesity alters our internal “set point” – our body’s notion of what our weight should properly be – which in turn drives calorific consumption if we start to slim back down. It used to be thought that operations like a gastric sleeve worked purely by reducing stomach capacity, but recent research suggests they also alter the balance of hormones that signal hunger and satiety, which seems to reprogram the set point.

There are so many facets, though. Rates of depression are five times higher among obese patients. Some of that might be effect, but much will be cause. Manda’s operation was performed competently but it wasn’t having the desired outcome because of the lack of dedicated psychological and dietetic aftercare.

I wrote to the local Tier 3 team and asked them to take her on. They declined: just because Manda had taken matters into her own hands it didn’t mean they suddenly had any capacity. They did send me information about the nutritional consequences, so I can at least make sure she doesn’t develop any vitamin deficiencies, some of which can be serious. But other than that, she’s on her own.

Properly supported, bariatric surgery will substantially lower weight for many people, and prolongs life expectancy as well as reducing rates of conditions such as diabetes and heart disease. Through a narrow cost-effectiveness lens, we should be doing lots more of it. Through any other lens, our politicians should be creating policy to counter the forces in society that are driving the obesity epidemic. In the absence of either, we will see many more Mandas. Fifteen years ago, there was much hand-wringing about “health tourism”: people coming to the UK to obtain free medical care. It’s a telling indictment of the state of the NHS that the travel is now firmly the other way.