Obesity: How Prejudiced Is the NHS?

In Britain, we have a serious problem with our weight.

More of us are getting heavier and suffering from ill health.

But who's to blame?

The cost of obesity is now so great, it threatens to bankrupt our NHS.

But what if I were to tell you there is a treatment

that could help tackle our obesity crisis?

I've never, never lost weight like that before.

One we're not using because of an anti-fat prejudice.

Why is it any different for fat people?

Why do they have no responsibility?

We don't wake up in the morning and think, "Today, I want to be fat."

A bias that may even extend to our health service.

I think there is a deep-rooted prejudice

in some quarters as well.

Meaning many patients aren't getting the best available care.

I felt like I was completely dumped by the very people

that were supposed to offer me all of the help that I needed.

A prejudice that has made the problem worse for us all.

I'm ashamed to work in a health care profession

that actually treats people in such a manner.

And we shouldn't be doing it.

I'm Professor Rachel Batterham,

a doctor and research scientist at UCL,

looking at differences in genes and body chemistry

that means some people are more likely to put weight on than others.

What we're learning in the lab should be shaping the future

of obesity care in the UK.

But there's a reluctance to accept what this could mean

in terms of treatment.

There's a battle brewing within our NHS about the best way

to deal with our obesity crisis.

One, two, three.

Between those who view obesity as a lifestyle issue

and those who see it as a disease

that needs specialist treatment and even weight loss surgery.

Knife, please.

I know most people will disagree with this,

but I'm very much in the camp that see obesity as a disease

and I've long argued that we need to increase

the number of weight loss surgeries funded by the NHS.

So there we can see the new egg-sized stomach.

Before I start to make my case, let's meet someone who's just had

weight loss surgery and is about to receive some life-changing news.

Robert had weight loss surgery yesterday

and we're running some tests on him.

It's not to see if he's lost any weight.

It's too soon for that.

But it's not too early to see if it's had an impact on his diabetes.

-Hi. Good afternoon, Robert. How are you feeling?

-A lot better.

Yes, I'm feeling really well.

I didn't think I'd feel this well, if I'll be honest with you.

-So you've had the diabetes for eight years, is that right?

-Yes.

And what's it been like? How has it affected you having it?

When you first find out you have it, it affects you really bad.

You hear stories about people losing limbs,

going blind and I've had family pass away with diabetes.

-Of course.

-So it's been very frightening, yes.

And what's your sugars been like since the operation?

Since the operation, his blood sugar level has been,

even when he's been having his soup and teas,

between five and six, so...

Your sugar is normal. It's just truly amazing, really.

Just less than 24 hours after the operation.

You're not going to need any more tablets when you go home today.

The diabetes has gone into, I hope, long-term remission.

This is just so life-changing.

I'm absolutely overwhelmed.

Yes. How lucky am I?

'We've known for over 20 years that weight loss surgery

'can put type 2 diabetes into remission,

'even before the patient has lost any weight.

'I can't understand why we're not doing more of these operations.

'It can transform someone's life

'and help cut the mammoth bill of this disease to the NHS.'

No medication. 18 hours after the operation, off I go.

Type 2 diabetes costs the NHS nearly £8.8 billion each year.

In less than 20 years,

it's estimated it will cost us 15.1 billion.

That's £280 million each week

or a staggering 1.7 million every hour.

Weight loss surgery puts over 60% of patients

with type 2 diabetes into remission.

Despite this, Robert could only get his life-changing treatment

on the NHS by chance.

Being a taxi driver, I was driving around last September in 2015.

A gentleman puts his hand up,

gets in and ends up explaining to me he was a surgeon from UCLH.

He then says, "Would you be interested in having

"this surgery done to help you out?"

And it all started from there.

So if you'd picked up somebody else, then you wouldn't be sitting here?

I wouldn't be sitting here now.

It was the right time, right pace.

Your whole access to treatment for your diabetes and your weight

was just complete luck.

Yes.

That's really quite shocking.

Yes.

Thank you.

I find it really concerning that this is happening in today's NHS.

Robert's access to treatment was not based on a medical pathway,

it was pot luck.

What's even more worrying is that there's thousands of other people

just like Robert who don't know that weight loss surgery

really could change their lives.

In the UK, severe obesity rates have trebled over the last 30 years

and type 2 diabetes has seen a similar rise.

But in the last five years, there's been a 30% fall in the number

of weight loss surgeries on the NHS,

with only 6,000 undertaken last year.

I've come to Chichester to meet Chris Pring,

a bariatric surgeon at St Richard's Hospital...

-Good morning, Chris.

-Nice to see you.

'..to see if he knows why there's been a drop in numbers.'

And how many operations are you doing a year at the moment?

We're probably doing about maybe 350 cases a year.

A few years ago, we were probably doing about maybe 600 cases a year.

So in the last five years, I'd say we've seen

quite a significant drop in the number of cases that we're doing.

And why have the numbers gone down?

It may be there's a bit of prejudice out there.

It may be that people don't feel this sort of treatment is, erm,

not only worthwhile, but deserved.

Do you think there's any prejudice within health care professionals?

Unfortunately, I have to say yes, I think there is.

I think there is a deep-rooted prejudice in some quarters as well.

This is surgery to improve health.

Diabetes, blood pressure, life expectancy.

This isn't surgery to lose weight.

And if we can get that message across,

then I think we will start to see our numbers increasing again

and rightly so.

And we will see, I hope,

that latent prejudice that I know exists,

we will see that being eroded.

It's shocking to think that people

could be experiencing prejudice within the NHS.

But it's something I'm hearing more and more.

Can it be true that people are really discriminated against

because of their weight?

-Hi, good morning, Richard.

-Hi, Rachel. How are you?

-Nice to meet you.

-Thanks for coming.

'We sent out a survey to the UK members

'of Lighterlife slimming group

'and asked them what they'd experienced as patients

'when they accessed the NHS for treatment.

'And Richard now has the results.'

We had 991 people get back to us and the response we got was staggering.

The first question that we asked was,

"Have I ever experienced any negative attitudes

"from somebody within the NHS because of my weight?"

The upsetting topline figure

is that 43% of the responders agreed with this.

So, almost one in two people with a weight problem

are experiencing a negative attitude towards them...

Whilst engaging with the NHS in their area, yes.

So, over a quarter of the people who responded

to the overall questionnaire were happy to take the time

to share quite personal stories

about the prejudice that they had encountered within the NHS with us.

Perhaps you'd like to take a look.

"I was refused a consultation with a view to knee surgery

"because of my age and my weight.

"I went privately.

"Otherwise I would have ended up in a wheelchair

"for the rest of my life.

"The operation was a success

"and I'm now able to walk normally again."

That's just unbelievable.

"I was refused a steroid injection in my hip

"as losing weight would be more beneficial, so I remain in pain."

"I was told by my GP that my health problems

"were all connected to my overweight.

"I did not have the confidence to argue

"and did not go back for three years.

"My diagnosis of multiple sclerosis was delayed by over four years.

"Due to this, I suffered in silence."

That is just appalling.

Working mum Gemma is another patient who felt badly let down by the NHS.

I was referred by the GP to the NHS weight loss service.

I think it was the most distressing actual weight loss experience

I've actually had.

They have the NHS Eatwell plate, which is a guide

to what you should have with every meal

and the different food groups within them.

I know that a lot of trigger in my weight gain are carbohydrates.

Potatoes, rice, pasta, bread.

They're all really bad triggers for me gaining weight.

I tried to explain this,

but I was told I need to conform to that plate.

In the time from starting to actually leaving the service,

I'd gained just over 2st by the end of it.

It was a horrific experience emotionally, physically

and has resulted in me being in a worse-off position

than I was before I joined the service.

Gemma only found out that she was eligible for weight loss surgery

on the NHS after seeing her surgeon privately.

Today's the day I find out if I can go on the surgical list.

We'll have an idea then of when my surgery will be, if I'm accepted.

Right, who's next?

Gemma Graham. 38. BMI of 47.

She wants a bypass.

But she'll need careful management.

Gemma's future is now in the hands of Chris and his team

of psychologists, dieticians and nurses

who will decide if she's suitable for surgery.

I couldn't sleep, couldn't eat.

My tummy's in knots. It's just...

It means everything today to me.

Kind of all my hopes are on a "yes" today.

-Hello, Gemma.

-Hi.

-Are you all right?

-Yes, good thanks. You?

Yes. Come in. Chris Pring. Come and have a seat.

-Have a seat.

-Thank you.

-Good, good.

Certainly, today, the team have assessed you for surgery

and we all agree that surgery's going to give you improved health

-and a better weight and better outcomes as a result.

-Fabulous.

This is keyhole surgery.

We staple across the stomach to give you a small stomach pouch.

We then divide the bowel down here.

We bring it up to the stomach pouch and we stitch it on.

So the food goes down the gullet into the stomach pouch.

It passes down the bowel here.

Thereby, the food bypasses this part of the stomach and bowel,

which we join on down here.

-The end of a long journey.

-Yes.

The end of one journey, the start of a new one. It is, yes.

We'll organise some dates for you and put you on the list.

Everyone's happy. You're all sorted now. There we go.

-Thank you so much for your help.

-That's OK.

-Thank you.

-Have a safe trip home.

-Thank you.

-See you.

Very relieved. I'm over the moon that I'm going to get the surgery.

It's a fantastic feeling and it's going to be a new beginning for me.

I think Gemma had got so frustrated with the system

because she felt that she wasn't getting anywhere.

She's here now as an NHS patient

and she's like a lot of people I see.

They can find it very difficult to navigate towards a point

where you will end up having a healthier weight.

For those lucky enough to get onto the surgical list

here in Chichester, weight loss surgery is a daunting prospect

and far from the easy option many people believe it to be.

What's happening here, the surgeon is actually dissecting

a little bit of your stomach tissue off to make you a new pouch.

It's about the size of an egg.

He cuts the bowel.

The bit of bowel that's been cut is then re-routed

and pushed up to the new tummy pouch.

OK? The rest of this stomach here, it stays there. We don't remove it.

-It stays there, but does it do nothing?

-Does it die?

No. It's perfectly fine.

And that's why you can reverse it because your stomach...

Yes, because everything is still there.

My first reaction to that is it's quite frightening.

This does frighten a lot of people.

With this type of surgery,

post-surgery and getting back to eating, you are on the equivalent

of around about two tablespoons of pureed food per meal.

If you try to eat any highly refined sugared items

with this type of surgery, you get a syndrome called dumping syndrome.

The food comes into the pouch, it then hits a part of the bowel

where it's not used to having large molecules of sugar.

It throws the body into a bit of a spin so what you then feel

is faint, sick, sweaty, nauseous, it can give you an upset stomach.

It's not pleasant and it happens to most people.

Any operation carries a risk.

So risks of infection, risk of bleed,

risks of deep vein thrombosis, risk of chest problems.

Probably around about one in 100.

I want to see my child grow up and I don't want to die young.

My dad died at 42 of pancreatic cancer, which is a lifestyle cancer.

He was overweight for years.

He drank, he ate what he wanted.

But, in the end, he died very young and I'm only two years away

from that age and it frightens the hell of me.

Yes, and that's the help we can give you

is to avoid you being in that position.

-And it's giving you almost a second chance, isn't it?

-Yes.

In terms of how your GP have helped you,

have you felt that they've been supportive?

It took for me to find a very, very lovely sympathetic GP

who I'd sat down one day with

and I literally, I did cry, and I said, "This is all facing me.

"I don't know what to do," and finally got a referral

because doctor after doctor after doctor just refused to refer me.

'I think today shows us that it's really hard for people

'to access surgery,

'even when they're eligible under current guidelines.'

You get a bit stiff sitting down, don't you?

'In England, the National Institute for Health and Care Excellence

'recommends weight loss surgery for people with severe obesity

'or with a BMI of 35 or more

'with a significant disease like type 2 diabetes.'

Thank you. See you later.

'Wales and Scotland follow similar criteria, but in Northern Ireland,

'it's policy to only provide surgery in extreme circumstances.'

Getting referred for weight loss surgery is hard enough,

but there's another obstacle.

'Before anyone can be assessed for weight loss surgery,

'patients are required to complete a diet and exercise programme

'known as Tier 3 for up to two years.'

-Hi, good morning. Great to see you.

-Welcome to RIO.

Let me give you a tour and show you what we do here.

'I've come to Rotherham to meet Dr Matthew Capehorn,

'who runs one of these programmes.'

We've got specialist equipment built for patients with severe obesity

and we can actually tailor exercises specific to the individual.

If they've got heart problems, we start off very gently and build up.

'Not everyone here will want surgery,

'but for those who have considered it, like Carol,

'Tier 3 will help determine if it's the best course of treatment.'

My initial thought was maybe I should try bariatric surgery

because I had done diets and they had failed.

-At that point, I weighed 21 and a half stone.

-OK.

And that was quite horrific and my BMI was 49.

And in the last 18 months, I've gone down to 15st

and my BMI is now 34.

-That's brilliant.

-So it has been a very radical change.

-Absolutely.

Hopefully, surgery won't be necessary

because I know what I'm doing now.

I know what I need to do.

It is so important to have the right mental attitude

and to develop that mental attitude

because, effectively, this is a lifelong change.

Sometimes it's the ups and downs of that weight loss....

Diet and exercise is only part of the programme.

To be effective, patients attend therapy sessions

and behavioural workshops.

So what we'll do now is we'll go into one of our group sessions,

which is a problem-solving session

for patients that are finding it difficult to lose weight.

Lots of people out there, including health care professionals,

who say, "Weight loss is simple,

"you just need to eat less and exercise more..."

Yes, but it doesn't work for everybody.

I think it's quite ignorant for people to think things like that,

unless you've been in the situation and you're finding yourself

struggling every single day.

We don't wake up in the morning

and think, "Today, I want to be fat."

You don't. It happens over a period of time

and usually by the time you've found out, it's too late,

you're already overweight.

So all you can do then is try and stop that

and try and work your way backwards to be healthy.

People can binge drink, they can take drugs,

they can smoke and things like that, but if you're overweight

you must be lazy, you must eat loads and all this.

I think there's too much prejudice

involved with people that are overweight.

I've seen it.

People will nudge other people. You know, "Have a good look at her."

It does hurt because you know that you're really trying your best

and what I've found with coming to RIO is,

it's helping me realise that these people,

they are ignorant, I do agree with you,

for having those opinions

because, unfortunately, through my upbringing,

I didn't know this is a good food, this is a bad food.

So now I'm re-educating myself as to what goes in

and what these foods will do to help myself lose that weight.

Thank you so much for being so honest.

I really appreciate your time and we'll leave you to your session.

-Thank you. ALL:

-Thank you.

'I'm impressed with what I've seen.

'This service helps over 1,000 people every year

'and I think it's the ideal preparation for the small number

'that then go on to have surgery.'

So the key thing is, bariatric surgery or weight loss surgery

is the most cost-effective weight-loss intervention

for certain people, if it's the right person.

But who's doing that screening?

We need Tier 3 centres like this to identify the right person

and also to treat the patients who, for whatever reason,

aren't suitable for the weight loss surgery.

You've got a fantastic service and facilities here.

Is your funding going forward secure?

No, it isn't in the slightest and it's very frustrating.

We only have secure funding until July of 2017 and so we could end up,

despite all of the great services that you've seen,

we could lose all of it.

That's worrying.

How will our Rotherham patients feel if they lose the one place

where they know they can come to where they get free NHS advice

and support to actually help them lose the weight,

become more healthy and get them that surgery?

They must feel like second-class citizens.

With services like this at risk of closure, it's clear to me

that we're just not taking the obesity crisis seriously.

If we're not getting it right here in Rotherham, that has one

of the highest obesity levels anywhere, then what hope do we have?

Without NHS diet and exercise programmes, people will be left

with no support to lose weight or a pathway to surgery.

Surgical intervention is the most effective treatment

for long-term weight loss and improved health,

but I'm concerned some patients don't even have access to Tier 3.

'Last year, Professor John Wass carried out a report

'on the availability of NHS Tier 3 services across England.'

-Good trip?

-Lovely, yes. I'm sorry about the weather. Terrible.

John, you carried out this survey looking at Tier 3 provision

on behalf of the Royal College of Physicians.

How comprehensive is access to treatment?

It's far from comprehensive.

There's only 67% of the country covered now,

so there's 30% or more not covered

and that means there's a real postcode lottery.

There is not adequate provision up and down the country to Tier 3

and therefore to the surgery

and I really do worry that the situation is going to get worse.

'The NHS needs to be doing far more for people

'struggling with their weight, but not everyone shares my opinion.'

"I am a fatist.

"I find obese people unappealing and they are a strain,

"not only on their clothing, but on NHS resources.

"The obese should pay for their treatments."

Amanda Platell is a well-known newspaper columnist.

Her views are read by millions.

What this is doing, it's fuelling a public anti-obesity agenda.

How are we going to even think of obesity as a real health problem

if we're saying it's totally down to the individual?

'As a professional who works with obesity every day,

'I want to understand where Amanda's prejudice comes from.'

-Nice to meet you.

-It's good to meet you.

Thank you so much for agreeing to chat with me today.

I did have second thoughts about it because we do have

quite different views on this whole subject.

So for a person who is really struggling to lose weight,

to read something in the newspaper that,

actually, it's all their fault

and they should have no support from the NHS,

I think that's quite a damaging standpoint to take.

These are self-inflicted conditions.

People stuff their faces with too much food

and don't get off the sofa.

You've spent all this money on wrecking your life

and wrecking your body and now you expect us to pick up the tab.

I think that's a very interesting view.

There are lots of people not getting any treatment,

there are lots of old people who are not getting meals provided for them

because so many billions now

are going into treating people who are fat.

We know that, actually, weight loss surgery

reduces the cost of the drugs, reduces the chances of dying by 40%.

Gastric bands, basically. That's what you're talking about.

-It's not gastric bands.

-OK.

So it's specifically not gastric bands, it's gastric bypass.

-OK, so it's much more severe.

-It's gastrectomy.

Well, if they had surgery today,

they would most likely go home tomorrow off all their treatment.

And when people come back six months after surgery,

they've lost my body weight and more.

And that weight stays off for lifelong.

It's not that it restricts the ability to eat,

it changes the way their brain responds to food.

But surely if someone's faced with something like,

here's a drug we can give to a young mum with breast cancer

so she can have five extra years of life,

compared to someone who comes in really overweight,

the sympathy is going to be all in the other direction.

But you've highlighted some of the key problems

that come with overweight and obesity.

As you increase your body fat mass, then your chances of dying,

your chances of diabetes, your chances of cancer really escalate.

That's the interesting thing you've said.

If you're fat, you're much more likely

to get a whole range of cancers.

But that education isn't out there.

You know, I can see on a pure calculation,

if you take someone who is not treated

and is obese for their entire life,

they're going to be a huge burden on the NHS and the taxpayer.

And if you just take the cold hard facts - a really obese person,

an operation that will be paid for on the NHS

to treat them within a few years, the outcome of this

is that they will not go back to being obese again.

-Yes.

-It's kind of a win-win.

It's incredibly effective.

But we're not using it in terms of a treatment.

The right information just isn't out there, but if I can sway Amanda,

I'm hopeful society's views towards weight loss surgery

can also be changed.

Prejudice against weight can leave people like Mark

feeling unworthy of help.

'I wish something had worked and I didn't have to have the operation,

'but I know that it's the only way

'that I can get out of the hole that I've dug...'

-Nice to meet you.

-You too.

-Come down.

'..many people would say myself and I accept that.'

-Come and have a seat.

-Thank you.

'At the end of the day, the only person to blame is myself.'

So, your weight is at the moment 196kg.

-That presents a significant challenge to your health.

-Yes.

Not only just your sciatica, but your health in general,

life expectancy, all this sort of thing.

So there's no doubt that moving for surgery

to help you reduce your weight and get you to a healthier weight

is going to be your best option.

I'm sort of, like, worried a little bit

because half of me is thinking I really need this surgery,

-but then the other half is thinking do I deserve the surgery?

-OK.

This is the picture that gives me a little bit of inspiration

cos I would like to get back to the way I looked then.

I'm about 29.

It's not a good sight, is it?

It's not a good sight at all.

I'm sorry, I've got to sit down again.

Mark has sciatica, a trapped nerve, that is restricting his mobility.

He has to take painkillers at 3:30 every morning

so that he can work as a driver.

I got lost in the system

and I then took matters into my own hands and phoned up.

They said, "You've been in the system too long,

"we need to move on now and get you the surgery as quickly as possible."

Normally, it's about 18 months to go through the programme.

In my case, it just ended up that it was about four years

and I know that the only way now is to have that operation

because I know that it will basically save my life.

And if I carry on the way that I am

or if I'm left the way I am, I will die.

We know that for people in your situation,

an operation is going to give you the best health outcome,

not only in the short term, but in the long-term.

When we look at life expectancy, when we look at the chance

of you having a lower risk of heart attack, a lower risk of stroke.

I mean, look, you're young.

You're only 56 so you've got a lot of time ahead of you,

so you need to have healthy time of it.

And I would say to you

that over the course of the next six to eight months,

you will probably lose about 1st a month.

The most important thing is that it's the right thing for you

and it's the treatment that's going to make you healthy again.

I'll see you again on the day that you have your operation.

Smashing, you don't know how much of a weight that is from me.

-Good on you, Mark.

-Thank you very much.

-We'll get there.

-Right, let me show you out.

-Thank you.

I think, if this was another health issue, there'd be more emphasis

and determination in seeking effective treatments.

But I think, as a health community,

we are tending to ignore this as a problem,

and this isn't difficult on an individual level,

this is difficult on a global level.

And we are suffering, in the Western world particularly,

from the health consequences of weight.

Let's look at the bigger picture here in Britain.

How widespread has the obesity crisis become?

Figures published by The Lancet show

that there are 14.5 million people with obesity in the UK.

And it's estimated that, by 2030, this number will rise

by a further 11 million new cases across Britain.

And what are the costs?

Currently, the NHS spends

£5.1 billion every year on obesity.

This is expected to rise to £10-12 billion by 2030.

Despite the rise in obesity,

the numbers of NHS surgeries are falling.

The European average is 50,000 operations each year.

But here in the UK, we only do just over 6,000.

The only option for some people is to go private.

52-year-old Karen was so desperate,

she felt she had no option but to pay for her surgery two years ago.

That's what I used to look like.

I was quite ill, I was sort of bloated out with water retention,

and it was causing all my other organs to fail.

I was too young to die.

But it would have been on the cards if it had carried on.

You never used to like your picture being taken before.

-Oh, no, I do now.

-It was very hard to get a picture of you.

The surgery actually cost me £11,000.

I had some inheritance from my mother's estate

which led to the fact that I could have it done.

I was 25st there.

And this is me at 12½ stone.

It's just such a difference.

That's my mum.

She never got to see my transformation.

-She always wanted you to lose weight.

-Yeah.

It is bittersweet that she never got to see it.

I'm sorry.

I don't think I could have taken the risk going on the Tier 3 system

because I don't think I could have waited that long.

I don't think I would have lasted.

In England, there are 209 clinical commissioning groups - CCGs -

who are given two-thirds of the NHS budget.

CCGs have the responsibility of how to spend that money,

and the situation for obese people

in many parts of England is about to get worse.

They face being denied access to routine care,

like hip operations,

that are readily available to non-obese patients.

If you're in the Vale of York

and you have a BMI of over 30, which is obese,

then you can't have orthopaedic surgery to replace a knee.

The bottom line is that the money is not there

And this means that this group of people is actually disenfranchised.

They're actually illegitimately sort of victimised, if you like.

There are some people that have been waiting for huge lengths of time.

So, in certain areas of the country, if you have a BMI over 30,

then you're discriminated against in that you can't have access

to surgery that other members of the population can have.

How can that be fair?

It's not fair.

And it's not just the Vale of York CCG

delaying treatment based on a person's BMI.

A recent report from the Royal College of Surgeons

found that about one in three CCGs have a mandatory threshold

to access surgery based on weight and smoking status.

We asked the Vale of York CCG for an interview.

But they declined our offer.

A number of CCGs with similar criteria also refused

to explain the rationale behind their policy.

However, north-east Essex CCG, who have a BMI threshold

of below 35 for routine surgery, did agree to speak to us.

This shouldn't really be seen as a cost-cutting exercise

because what we're hoping for is that

when we have patients who have a body mass in excess of 35,

they're able to put into place a change in their lifestyle

that allows them to bring their body mass index below 35

and we can still carry on and have that surgical procedure.

But through the process, they may have gained a health advantage.

If you start discriminating on who should have treatment

on the grounds that there are one lot perhaps who are seen

as secondary citizens because they happen to be overweight

compared with those that have led a more healthy life,

I think that's creating a two-tier NHS.

Now, that's not good.

That is rationing on grounds that really are not humane.

Bear in mind, this isn't meant to be a punitive measure,

it's meant to be around improving better health outcomes

for our patients, and so that's why we put it in place.

NHS England issued a statement saying,

ultimately, these are legally decisions for CCGs,

but informed by best evidence and national guidance where appropriate.

69-year-old Helen is waiting for a hip replacement,

but she's been told to lose 5st

before she can be referred for surgery.

I've struggled with weight, really, since a child.

When I was ten, I had osteomyelitis,

which caused my ankle to be really misshapen.

As the years have gone on,

it's made my knee and my hip start to go.

It's like the chicken or the egg.

Which comes first, the losing of weight,

which isn't going very fast, if at all,

or having the operation and being able to move around a little?

Five years ago, we went dancing,

I went to exercise classes,

I can't do any of that now because I can't walk fast enough.

I'll get... Well, if you bring it down for me.

-OK.

-Are you OK?

-Yeah.

I just think, in the future, if I don't have anything done,

I will end up in a wheelchair.

But I used to do all this area of gardening.

-That was her bit.

-Yes, that area was my bit.

And I just can't get down to it. It hurt too much.

We can't see any way out of it, really, this hip.

It's going to get worse.

And they keep on telling her that she's got to lose this weight,

but it's quite hard to lose weight when you can't exercise.

Okey doke.

I am getting worse, and I do feel as though I could be housebound.

I just...

Yes, I just find that...

um...it's something that will probably never happen.

How hard is it to lose weight when going it alone?

A recent UK-wide study of patients with simple obesity

by King's College London showed the annual chance for women

returning to normal weight was 1 in 124,

and 1 in 210 for men.

For those with severe obesity, it was 1 in 677 for women,

and 1 in 1,290 for men.

To make matters worse, for the few who did lose weight,

78% put it back on after five years.

Mark's road to surgery has taken four years,

and today he's finally getting his treatment.

It's like the light is at the end of the tunnel.

It's a life-changing operation

and it's going to improve my life no end.

Many people believe Mark's treatment is too expensive.

And it's true to say

the NHS can't afford to operate on everyone who qualifies.

-Hello there.

-Hi.

-If you'd like to take your gown off...

A number of studies state that weight-loss surgery pays for itself

within two to three years due to savings on drugs.

A recent more comprehensive study by King's College

found that despite the cost of weight-loss surgery -

between £7,000 and £10,000 -

it's one of the most cost-effective treatments

of any kind available to the NHS.

There we go, all done. Thanks, Hazel.

Cheers, Sharon, Cheers, Rich.

We can't say it will save money

because Mark's life expectancy will increase

and it's impossible to predict what care he might need

as he becomes older.

But with existing weight-loss surgery centres,

we could increase surgery numbers to 25,000 each year

and help more people live healthier and longer lives.

Obviously, it's a second chance.

I just don't want to be like this any more.

I'm on my way to Harrogate to meet 59-year-old accountant Philippa.

Like many people in this film, she has multiple health problems

and has asked for weight-loss surgery,

but has been refused at every turn.

However, there's a chance I can help.

-Hi, Philippa.

-Hello.

-Lovely to meet you.

-Thank you so much for letting me come and see you.

-Come on in.

When you went and asked about weight-loss surgery,

can you remember what your BMI was?

Um, my BMI has been over 50 for quite a while now.

Um...

the overall impression that I was left with

was that I wasn't worthy of being considered.

I'm sorry to have to tell you this,

but you did qualify for weight-loss surgery

because you had a BMI of over 50.

-So...

-That's even more upsetting...

..that I was just dismissed.

So, what's happened since?

Having had the family here at Christmas...

..and some of them concerned about my general health...

..um, I decided to go back to my GP

and ask again about weight-loss surgery.

He was saying that because of my heart condition,

I wouldn't be referred for weight-loss surgery.

-What heart condition?

-I've got atrial fibrillation...

..which was diagnosed in September '15.

So you've had an irregular heartbeat for over a year and a half, really?

But the consultant said that,

because of my weight,

they weren't prepared to operate, to do even...

um...

to restart my heart.

So I seem to be in a Catch-22 situation.

We commonly see people with your heart condition,

if you can't have the heart condition treated

because of their weight, who we operate on,

they lose the weight and then they have the heart condition treated.

Potentially, if you'd had the surgery five years ago,

then you wouldn't have developed the heart condition

because there is a link between the two.

I'm ashamed to work in a health care profession

that actually treats people in such a manner.

-And we shouldn't be doing it.

-No.

I...I actually can't believe

that, basically, she's been left.

She has severe obesity, type 2 diabetes, a heart condition,

and she's stuck.

I just think that it's terrible that we're leaving people

in this situation with effectively no way out

and not supporting them at all.

Philippa needs surgery for health reasons.

I'm going to see what I can do to get her the help she needs

before it's too late.

I'm really concerned that more people like Philippa

will be denied access to weight-loss surgery

because of the recent funding changes for this treatment,

switching from NHS England to CCGs.

The way that weight-loss surgery is funded is going to change.

So it's going to go from being centrally funded

-to locally commissioned.

-Yeah.

What impact is that likely to have?

When the money comes down from NHS England,

I worry that it won't get ring-fenced,

so it could easily be absorbed in the CCG's general financial pool.

And we already know that there are huge members of CCGs

that are in financial difficulties, which is a real worry.

If Philippa doesn't get the help she needs,

her health is set to get worse.

I can't stand by and let that happen.

Her referral has been a real race against time.

And if I'd seen her just a few weeks later,

then she wouldn't have been able to access weight-loss surgery.

The CCG were arguing that she hadn't been through Tier 3.

Her CCG doesn't offer Tier 3,

so, effectively, Philippa is stuck.

Despite my intervention,

her CCG are still intent on refusing her treatment.

And this latest setback was hard for Philippa to take.

I received a copy of an e-mail to say that there was

no funding available and that I wasn't eligible.

I was numbed that evening.

I probably demolished more food in three hours

than a normal person would have eaten in one day.

We can offer her the Tier 3

and the assessment for weight-loss surgery at the same time.

So her CCG has finally agreed that Philippa can go forward

to be assessed for surgery.

Without my intervention,

I very much doubt that Philippa would be alive in five years' time.

I'm just...

..one of the lucky ones that...

..I've been given this opportunity.

If we're serious about tackling obesity,

we need effective prevention and treatments, including

investing far more in surgery, as the results speak for themselves.

26-year-old Michael had weight-loss surgery

here at UCLH just nine months ago.

I weighed about 28½ stone

and this was four or five weeks ago now,

where I've lost 7st 13lb

where I'm now 22st,

which is quite a big difference.

Michael is now helping us with our research

to understand the benefits of surgery.

-How are you doing?

-You look fantastic.

-Thank you.

-Since last time I saw you.

-I'm feeling very well,

-thank you, yeah.

-Sit down.

-Cheers.

'What makes this treatment successful long-term

'are the biological changes to the body.'

So, what taste changes have you noticed?

Realistically, it just feels like

everything is being taken up a level in sensitivity.

Saltier foods, fattier foods,

you can bear them a lot less than you used to be able to.

But I think mainly it doesn't amplify the sense of taste

is what I've noticed,

which ensures you have a greater balance and variety

of what you have, rather than having the same things,

the same textures and same tastes over and over again.

Our research is helping us to understand why some people

are more likely to put weight on than others.

We'll be giving you three samples, and for each one, I'll ask you

to taste them and tell me which one tastes different to the other two.

OK.

What we're seeing is that immediately after surgery,

the hormones coming from the gut that are present in the blood

completely change, and we know that these hormones act on the brain

to control how hungry a person feels.

We also know that these gut hormones affect taste

because they bind to the taste buds in the mouth

and change what sort of food a person will crave for.

I'd say the first one is definitely different.

When a person has surgery,

what our research is really helping us to understand

is why weight loss with dieting

is so difficult for the vast majority of people,

whereas weight loss with surgery and the changes in their hormones

actually really help them to continue to lose weight,

but, more importantly, to keep that weight off in the long term.

We know some people are predisposed to gain weight.

But the latest research doesn't seem to be widely understood or accepted,

even amongst health care professionals.

'If we're going to increase the number of NHS weight-loss surgeries,

'we need to educate the wider medical profession

'on how the surgery works.

'So I've invited a group of GPs and CCG commissioners

'to share my research with.

'These are the people I have to convince.'

Thank you, all of you, for coming today.

I really need your help to try and understand why GPs and commissioners

are not really pushing for more access to bariatric surgery.

So, how is it working?

It's become recognised that the gut plays a key role

in regulating how hungry you feel and also your blood glucose.

Now, there's a gut hormone called peptide YY.

And when a person eats, the levels in the blood go up

and they stay elevated for several hours,

depending on what you've eaten.

Children and adults with obesity have low levels of this hormone

that tells your brain if you've eaten.

So, when they eat, the brain isn't getting the right signal

to say you've eaten enough food.

Ghrelin, which has been dubbed the hunger hormone,

we know that this hormone again acts on your brain to tell you to eat.

After surgery, PYY, which is a fullness hormone, they go up.

Ghrelin, which is the hunger hormone, goes really down.

And why do we get the taste changes?

Well, in your saliva, you have all these gut hormones

and your taste buds have got receptors

where these hormones bind to.

So, when we change these hormones coming from the gut,

we change the saliva and we change taste perception

and how people taste different foods.

Patients no longer feel hungry.

And when we image their brain,

their brain now responds completely differently

when we show them pictures of food.

By replumbing the gut, we're changing the nerves,

we're changing the micro-biome,

and it's all of these things together

which lead to the beneficial effects of surgery.

I'd really like your comments

as to why you think that weight-loss bariatric surgery

isn't being more widely commissioned or being made available.

Well, first of all, I do confess

that I wasn't aware and perhaps it was more of a misconception

of the risk, or less risk,

in terms of the surgical interventions.

So, what's missing in order to really facilitate

the right treatment to the right person?

I guess... I feel that there probably is lack of awareness

of what is the outcomes that can be achieved

of bariatric surgery, Tier 4.

And I wasn't entirely aware of the hormone studies

that you've quoted as well. It's interesting to see that.

I don't think there's any question that there is great benefit

in managing obesity and treating obesity.

The difficulty is that I think there probably is

a lack of information out there at primary care level

in terms of the benefits and balancing the risks.

And I don't know whether there's a great deal of public sympathy

out there for obesity. And I think that's a barrier.

I completely agree that this kind of surgery is extremely effective,

impressively effective.

But, for many people, and we are influenced by society at large,

many people's view is that morbid obesity is a lifestyle choice,

it's self-inflicted.

There's a lack of sympathy.

And that impinges on the decisions that we make sometimes.

It's a pity, but I think it's the case.

I think that, as health care professionals,

we really need to instigate this.

See, I think, until doctors take it seriously,

how can we expect patients to?

We probably have got an unconscious bias over obesity.

-Thank you so much for your time.

-Thank you very much.

Really appreciate it.

I think raising that scientific justification

for bariatric surgery is the biggest take-home message.

As a commissioning group,

we would be accountable to our population for our standing.

So it's just about getting the country better informed,

as well as clinicians, around the benefits and the merits

for bariatric surgery.

I find it quite surprising that there seemed to be

a lack of understanding of the health benefits

and also a complete lack of understanding

of how the surgery works.

It tells me that we obviously need to do

a lot more to actually get out to CCGs, to talk to GPs,

about the health benefits that surgery can bring.

It's just over three weeks since Mark had his operation.

So, what I've got here tonight is some potatoes,

boiled potatoes, fish in a parsley sauce, and that's basically it.

Tonight's dinner.

I've actually lost about 1½ stone.

I've never, never lost weight like that before.

In all of the diets, all of the plans that I've been on,

I've never lost anywhere near as much as I have now.

It's been a life change already, and we're just three weeks in.

This meal here is going to take me

at least 20 minutes to eat.

If not longer.

Because I try to let everything settle before I take another bite.

Sometimes you feel it going down

and, er...

..it's...there's like a little button,

it's the best way to explain it,

that you sort of think, you know, "Is that too much?"

Or, "Did I chew that right?"

That's why I tend to try to use just half a teaspoon at a time.

So I don't put too much in.

Ever since the op, I've felt a different person, to be honest.

I'd been out for a meal, not a problem.

I just order from the kiddies. The kiddies menu.

So I'm a cheap date.

This has about done me, to be honest.

And the other beautiful thing is, since the operation,

I'm actually off my meds as well, completely.

My blood pressure has gone back to normal.

Happy days.

We all know someone whose life is affected by their weight.

I began the programme by asking who is to blame

and why more is not being done to tackle our obesity crisis.

Commissioning of obesity services to help people manage their weight

is a postcode lottery.

Worse still, many of the people that we've met,

including health care professionals,

believe that there's a prejudice within the NHS that is preventing

people struggling with their weight from accessing health care services.

Weight-loss surgery really can transform a person's life.

But despite this, I fear that the number of operations undertaken

is going to fall even further.

This will effectively condemn thousands of people

to years of unnecessary ill health.

Rather than adopting a postcode lottery approach to treatment,

we need to make sure that people can access specialist obesity services,

including surgery.

Both to tackle our obesity crisis, but also to preserve

the central ideal of our NHS -

of providing good health care to all.