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Tuesday, 1 April 2014

Injustice, Body Contouring and the Postcode Lottery

A few weeks ago, a patient came to see me in my private rooms. She had lost the equivalent of a small person in weight and wanted to "feel like a woman again". Her abdominal apron hung over her pubis to mid thigh. Her waist was 34 inches, but she had to buy 48 inch trousers to fit her abdominal apron into them. Her breasts were empty and deflated, the nipple hanging at the lowest part of the breast curvature. She was in her early 30's.

She satisfied all the criteria for body contouring as laid out by the CCG covering my NHS practice so I offered her the surgery on the NHS. After all, I had performed abdominoplasty, medial thigh lift and mastopexy on a similar lady only a couple of weeks previously on the Nash. Funding for her surgery was declined. Her CCG excluded funding for any type of body contouring. Had she lived 2 miles further South, she would have had the surgery funded by our CCG. I performed fleur-de-lis abdominoplasty and mastopexy privately. It has already transformed her life completely.

How can this possibly satisfy anyone's idea of the fundamental ethical principle of Justice? Weight loss surgery itself is commissioned universally across England for patients who fulfill the criteria. We have a duty of care to these patients and this duty is not satisfied if we convert one health issue into another.

In a recent study, 147 Primary Care Trusts in England were asked for information regarding provision of funding for body contouring after massive weight loss. Of the 67 who replied, 23 excluded all forms of body contouring procedures.

Before, dear Reader, you wax lyrical about funding availability for cosmetic procedures, let's be clear about something: the primary drive of this surgery is not cosmetic. Of course, there is a cosmetic aspect to it (as there is in almost all forms of plastic and reconstructive surgery), but this is not the reason that this surgery must be offered to patients on the NHS.

Research demonstrates significant improvements in patients’ physical function, emotional wellbeing, body image satisfaction, identity shifts, sexual vitality, greater wellbeing and quality of life once they have undergone body contouring surgery following massive weight loss. The NHS has a habit of running false economies. When I was a Burns Registrar at Chelsea & Westminster Hospital in London, I remember a particular case where a patient had a burn to their foot that had been treated surgically. He was fit for discharge but required dressings as an outpatient. They could not drive and, because of the dressings, they could not go home by public transport.

"Could the hospital pay for a cab to take me home?" the patient asked (quite reasonably, I thought).

 But nothing is so simple in the NHS. Rather than pay £30 for a taxi to take this chap home, the hospital management (in their wisdom) decided that he should stay in hospital (at a cost of around £700 per night on a specialist burns unit) until such a time as he could get on a bus. Bonkers.

So let's apply this to body contouring. The cost of the body contouring procedure is understandably high. However, so is the cost of psychological counselling, treatment for recurrent skin infections, time taken off work, back pain, neck pain, joint pain, recurrent urinary tract infections etc... the list goes on and on and these are all things can be attributable to the excess skin left behind after weight loss. Equally, all of these things (that can go on causing problems for the lifespan of the patient) can be addressed with a one-hit surgery. Go figure.

If you haven't already, please read the BAPRAS guidelines. I agree whole-heartedly with what lies therein.

The sooner that these guidelines become NICE guidelines, the better. It's time that all patients received a universal standard of care in this country, regardless of where they live. That's Justice.

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