Why is it so difficult for obese people to access life-saving weight-loss surgery in our public health system? By Megan Howe.

Slim pickings for obese Australians needing bariatric surgery

A morbidly obese patient is prepared for a laparoscopic sleeve gastrectomy.
A morbidly obese patient is prepared for a laparoscopic sleeve gastrectomy.

If you need a hip replacement, or perhaps cataract surgery or a pacemaker, the door to public hospital treatment may not be flung wide open, but it’s certainly ajar. While patients often face a wait, those procedures are performed in public hospitals around the country every day.

But what if you need surgery to treat a disease that now affects 28 per cent of the Australian adult population, and is responsible for 5 per cent of all deaths a year worldwide – obesity.

While weight-loss or bariatric surgery has long been shown to work and to be cost-effective in the severely obese or those with associated complications, the chances of getting the life-saving surgery in a public hospital are very slim, says Professor John Dixon, head of clinical obesity research at the Baker IDI Heart and Diabetes Institute in Melbourne.

Nine out of 10 Australian bariatric patients have their surgery in private hospitals, using private health insurance or savings, getting a loan or dipping into their superannuation to pay for it.

Unlike other chronic diseases such as diabetes, we have no system of care for obese Australians – and there is no responsibility on health professionals to treat patients who are grossly overweight, Dixon says. And unlike countries such as Britain, we have no system for assessing obese patients to establish who needs surgery and what priority it should be given.

“We have this knee-jerk reaction in our community that surgery is so expensive and so difficult we can’t provide it for all,” he says. “That is just not true.

“We do cataract and pacemaker and joint replacements for those who need it. If these people need [bariatric surgery], it is cost-effective, proven to save lives, improves the quality of life and improves productivity, [then] we should be doing it.”

There are three main types of bariatric surgery for weight loss – adjustable gastric banding, sleeve gastrectomy and gastric bypass – all of which require lifelong changes to diet and lifestyle to be effective.

The National Health and Medical Research Council 2013 guidelines recommend the surgery as the most beneficial and cost-effective management for motivated individuals with severe obesity.

And a study published last August, which followed up 65 patients in a pilot program providing bariatric surgery in two Sydney health districts, confirmed it is efficacious in the public system for obese patents with co-morbid conditions – or conditions associated with obesity such as diabetes or sleep apnoea. The patients’ mean weight loss within two years of surgery was 39.9 kilograms. Most significantly, there was full or partial resolution of type 2 diabetes, hypertension and obstructive sleep apnoea in most participants by two years. 

The study noted that the annual cost of managing an individual with type 2 diabetes had previously been estimated at $9095-$15,850, mainly going towards medication, medical consultations and hospitalisations. With the bariatric surgery and associated care costing $9000-$11,000, the surgery would pay for itself in a year by eliminating those costs in patients with type 2 diabetes, the authors wrote.

Yet public patients often can’t get on a waiting list, let alone get surgery, Dixon says.

In a pre-election health debate in August 2013, then federal health minister Peter Dutton said he was “open” to discussion with the states about investment in bariatric surgery. Yet not much has changed since the government came to power.

In New South Wales, there were 424 surgical procedures to treat obesity in 2013-14, although only 251 were for insertion of obesity-control devices, with the remainder for the revision or removal of such devices, according to figures from the Ministry of Health.

Queensland Health reports there were 198 bariatric procedures done in the public system in 2013-14 but there is no specific policy regarding access to bariatric procedures. In Western Australia, where there is a clear policy on eligibility, there were 530 bariatric procedures performed on public patients in 2013.

There were 692 bariatric procedures in Victorian public hospitals in 2013-14, with a spokesman saying the 2014-15 state budget committed $8 million over four years towards care for bariatric surgery patients.

Dixon believes bariatric surgeons have little incentive to change the current system, because they benefit by directing patients into the private health system. “We can’t deliver surgery to the 1.5 million people who might be eligible, but at least we can open the door,” he says.

One surgeon keen to push open the door to public patients is Professor Michael Edye.

Edye, professor of surgery at the University of Western Sydney’s Blacktown-Mount Druitt clinical school, says bariatric surgery should be viewed not as weight-loss surgery, but as surgery for complications that come with being overweight.

“It’s almost like a new disease that has come along. It’s like a new form of cancer has presented itself – it’s that serious, in terms of the long-term effects,” he says.

Edye co-authored an editorial in the Medical Journal of Australia last November calling for Australia to develop a framework within which obesity treatment, including bariatric surgery, can be offered to all patients who need it.

He says the federal/state health funding system gives states little incentive to invest in the surgery.

The federal government provides rebates for bariatric surgery through the Medical Benefits Schedule (MBS), but the state health systems foot the bill for the hospital costs involved in the surgery. However, it’s the federal health system that reaps most of the savings resulting from patients avoiding chronic disease.

On the day The Saturday Paper spoke with him, Edye was preparing to see a female patient seeking weight-loss surgery.

“If she has co-morbidities, I’ll say I’m not in the business of overweight surgery, but we can treat accompanying diseases. I’ll take this as a special case,” Edye says, suggesting this patient may be his first bariatric surgery case in the public system.

He would present the benefits of offering the patient surgery to his local health district and “see how they come at it”.

“I’m keen to push the envelope on this one a bit.”

The “huge prejudice” towards obesity in our community has led to there being little understanding or will to look at ways surgery can be offered widely in the public system, he says.

Trish Laban, who spent almost four years on a waiting list for bariatric surgery, says it was not until she was finally offered surgery at The Alfred hospital in Melbourne that she was “treated as a person with an illness, rather than just some fat lazy slob”.

Laban, 46, who gained 20 kilograms during her wait for surgery and suffers from depression, anxiety and fibromyalgia, finally had her gastric banding surgery in February 2013. A couple of months ago, she hit her goal weight of 85 kilograms – down from 170 kilograms pre-surgery.

“As a public patient I had to jump through so many hoops and wait such an incredibly long time, which I find ridiculous considering the so-called ‘obesity epidemic’ we’re in,” she says.

“I have a genuine medical condition, like so many others, and I consider the fact that it’s near impossible to get access to weight-loss surgery through the public system is nothing short of discrimination.”

She is now facing another long wait for breast-reduction and body-lift surgery to ease constant pain. It’s likely be 10 years before she gets that, she’s been told.

Dixon says that while our society blames obese people for their disease, our weight is largely determined by genetics, epigenetics (factors that turn genes on or off) and what happens to us in the womb.

It’s the first four years of life before our third birthday that determines whether we’ll end up thin or fat, he says.

“It’s not willpower or morals or compliance – it’s called physiology.”

Associate professor Wendy Brown, immediate past president of the Obesity Surgery Society of Australia and New Zealand, points out that obesity is a disease that doesn’t warrant a signature ribbon or colour such as breast cancer or HIV/AIDS. Instead, we marginalise people who are obese.

“If we stopped heart-lung transplants, we’d have people marching on parliament,” she says. 

If bariatric surgery were stopped, she believes there’d be no public outcry. “Yet in reality, treating obesity would provide more years of life for people.”

Brown says attitudes to obesity must change in order to influence decisions on spending.

“We need to create a general community feeling of empathy and an understanding that once you put on weight, it is very hard to lose it.

“Increasingly it’s to do with the society we live in and the fact we have got the genes of our forebears – it is very difficult to stop obesity.”

This article was first published in the print edition of The Saturday Paper on January 31, 2015 as "Slim pickings".

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Megan Howe is a Sydney-based medical writer.

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