Weight loss surgery on the NHS

Today I had my 4 in 1 assessment for bariatric (weight loss) surgery with the NHS.

In order to qualify for weight loss surgery on the NHS, you have to have a BMI over 35, although it can be lower if you have other comorbidities. However, the exact requirements vary from NHS Trust to NHS Trust.

You can’t be referred directly for weight loss surgery. Your GP has to first refer you to a special Tier 3 weight management programme that includes information sessions on various subjects including nutrition, emotional eating, exercise etc.

In my case I did my programme with a company called More Life, starting late July 2022, having asked my GP to refer me for the programme in February 2022. For the Tier 3 service to refer me on for surgery, I had to lose at least 5% of my body weight, I had to attend 80% of the sessions and also participate in at least two bariatric information sessions.

My start weight at More Life was 34 stone 2 pounds and by the time I was referred for Surgery in March 2023, I had got down to 31 stone, meaning I lost 9.2% or 3 stone 2 pound. Once referred for surgery, you are discharged from the weight management programme and expected to fend for yourself until your first appointment with the surgeons. For me it was a 13 month wait and when the appointment came, it was completely out of the blue, a telephone call that I nearly didn’t answer as I normally ignore private numbers.

In between the weight loss programme finishing and now, an awful lot had happened. I ended up in hospital last May with what turned out to be a blocked bile duct caused by gallstones. The doctors told me that I should have my gallbladder removed, but the surgeons would be unwilling to perform that operation because of my size.

By July 2023, I got down to 28 stone 10, but subsequently went through a nasty separation, divorce and bought a house. It was an incredibly stressful time and my diet gave way and I was worried this would effect my referral.

When the appointment to see the surgeons was made in March, I had regained 1 stone 10 pounds. I immediately got back into action and by the time of the appointment today, I was back to 31 stone 3 pounds.

I was pretty frustrated and disappointed in myself that I had put on so much weight, but at the time it was just a case of “survival mode”. If it wasn’t for the appointment, I would have continued to struggle. Having that appointment coming up was key to re-motivating myself, and going back to the good habits I’d gained during the weight management program.

When the appointment was booked, I was given a booklet to read, a check list and also a link to two videos to watch. I was also asked to join a Teams session with the Dietician and lead nurse. That provided me with the information about what to expect for today’s session. I was expecting to get a grilling, testing my knowledge about the procedures, the pre-op Liver Reduction diet and the post op diet etc, but that didn’t really happen.

Parking at the hospital, Salford Royal was a nightmare. It took me 40 minutes just to get into the car park. Luckily I set off 90 minutes before my appointment for a 30 minute drive, so I was still on time.

I walked straight past the clinic at first. It’s the Diabetes / Endocrine centre. Once I found the entrance, I was given a form to complete, a consent form for the Bariatric register, then asked to sit in the waiting room. The waiting room was packed so I stood outside it but within 5 minutes, I was called in to be weighed, then had some bloods taken. The staff were very friendly.

Then there was another wait, this time much longer. I was introduced to Professor Syed whom went through my medical history with me. One of the prerequisites for bariatric surgery is a sleep assessment. This is because people my size often have a condition called sleep apnoea, which means the airway is impeded during your sleep, preventing breathing, so your body wakes you up to catch a breath. They need to know if you have this as it impacts the anaesthetic treatment in surgery.

More Life told me to get my GP to refer me for a sleep study once they referred me for surgery. My GP referred me, but the sleep clinic initially refused their request. I had to complain again to my GP. They referred me a second time and I was given an appointment for February 2024, but in January, the appointment was cancelled with no explanation and no new appointment provided. In March I got a text message asking me if I still wanted to remain on the waiting list for the sleep study. I explained all this to Professor Syed and he referred me again, but from what I can gather from the patient forums, I could be waiting 6 months.

This is an issue because you don’t go on the waiting list for surgery until all investigations are completed first, and the waiting list for surgery is currently 12 months, so we’re talking another year and a half before I am operated on.

They also offered me weight loss injections in the meantime. I have been asking for these injections ever since they were first authorised by NICE, the organisation that controls what medicines and treatments can be made available on the NHS. The first time I asked, there was a national shortage and nobody was prescribing them.

I asked my GP again last summer. My GP took bloods and I was denied the injections because my blood sugars were normal and my cholesterol was good. I felt like I was being punished for losing weight already.

The injections work by suppressing the production of the hunger hormone Ghrelin, which means you don’t feel as hungry, making it easier to stick to a healthy diet. Weight Loss Surgery itself does the same thing, except to a more extreme extent.

Two months ago, I decided I couldn’t wait any more and got a private prescription through boots online doctor. It costs £199 for 4 weeks. I couldn’t really afford it, but I did it anyway and asked the GP if the situation had changed. They told me that only weight management programs could prescribe them. So, to be offered the injections by the hospital was a relief.

To be honest, I haven’t really felt any difference in terms of appetite so far on the injections. This may change as the dose increases as you start on a very small dose and increase each month. The big thing for me is routine and planning. I force myself to have breakfast, so I’m having two meals a day.

They made it clear that they don’t offer these routinely to every patient, but in my case, they really need to help me get my BMI down to about 55 to make it safer to perform surgery. The disadvantage is that whilst I’m being treated with the injections, I don’t count towards the waiting list.

I’m not a morning person and I don’t tend to feel hungry in the mornings so I always used to skip breakfast. I’d also skip lunch too as I developed a phobia of eating in front of other people that started after a classmate made a comment about the fat kid eating chips on my first day in high school.

My body is used to starving through the day then binging at night. I have to make myself eat breakfast to break the cycle. I also plan my meals out in advanced now. At the weekends I cook my proteins so it never takes more than 20 minutes to prepare a meal each evening. I either have 3 eggs or 2 chicken breasts or 2 lean pork loin steaks together with plenty of vegetables and a controlled portion of either brown rice, wholemeal pasta, a baked potato or mash potato. I use an app called nutracheck to register everything I eat and typically eat between 1500-2000 calories a day. To maintain my current weight, it would take about 3500 calories a day (this is before exercise). I’m aiming for 2 pounds loss per week, which is sustainable and this isn’t a temporary diet, I’m trying to develop permanent new eating habits.

After seeing Professor Syed, there was another wait before seeing the dietician, Chris. I explained to him my diet and how I was progressing, and he was happy with me although he wants me to see if I can increase to three meals a day. After surgery, I will be left with a very small stomach and that means I can’t eat a lot in one sitting. He said a quarter of a chicken breast might be a challenge.

Therefore, it’s important to eat small portions regularly, 6 times a day (every 3 hours) to make sure I can get enough nutrients. I need to eat protein first, as that’s important for muscle growth. I will not be able to eat foods with high fat or sugar content, or I risk overwhelming my body, causing a condition called dumping syndrome. The advice is to eat food no bigger than a 20 pence piece, chew it 20 times and stop eating no later than after 20 minutes.

After surgery, I will need to take vitamin supplements for the rest of my life as the surface area of my stomach won’t be enough to absorb all the vitamins I need.

You also can’t eat and drink at the same time, so it’s important to sip water throughout the day to avoid dehydration. Fizzy drinks and alcohol are off the menu. Alcohol, I can do without anyway, but I am used to drinking no added sugar pop like Pepsi Max and Coke Zero. The carbon dioxide will cause problems though. I have already cut down quite a lot and am sticking to sugar free cordials most of the time.

The last person I saw was the surgeon. He told me that because of my size, a traditional gastric bypass would be more difficult, so he suggested the gastric sleeve instead. Patients treated with the sleeve typically lose 60% of their excess weight in the two years following surgery. Patients who have had the bypass typically lose 75% of their excess weight.

The bypass involves creating a small egg sized pouch of stomach and redirecting the small intestines to connect to the pocked of stomach. Your original stomach is left inside but disconnected.

The gastric sleeve involves stapling the stomach so that all that is left is a thin tube of stomach and the rest of it is surgically removed. There are pros and cons of both. He said that I would be a candidate for 2 operations, initially having a gastric sleeve but if needed, I could later have it converted into a bypass to gain the maximum benefit.

I asked about waiting lists, and what he said to me was that what they would like to do is to see how I get on with the injections and the plan would be to get to the point where the weight loss plateaus via the injections and then operate so he couldn’t offer me a timeframe.

However, that did leave me confused as he also said that the clock doesn’t start until I’ve finished the injections and the waiting list is 12 months for surgery at Salford. Patients with a BMI of less than 55 for women and 50 for men that have less complicated needs are offered surgery at a private hospital called Oaklands, still performed by the same surgeons. The waiting list for Oaklands is 6 months but I don’t qualify for this.

The amount of time it takes from being referred by your doctor to having surgery can feel like a never ending process. You’re talking 3 years currently, but there are patients that have been waiting twice that amount of time. There was a time when I couldn’t see a light at the end of the tunnel. There is very little communication whilst you’re on the waiting lists so you have no idea when you will get a call. That can be very frustrating and demotivating.

However, I’m trying to change my mindset and instead see this as an opportunity to lose as much weight as possible, but at a sustainable pace, before surgery. The lower my weight, the easier the surgery will be and the lower the risk of complications. No operation is without risk. There’s a 1 in 5000 chance of death, most often due to blood clots, which is similar to the risk of surgery to remove your gallbladder.

Speaking of my gallbladder, I asked the surgeons about this as the doctors had suggested mine should be removed but the surgeons said it’s better to do it after I’ve lost weight after the weight loss surgery due to the complications of performing two operations at the same time. There is a risk I could have another blockage.

Losing weight increases the risk of gallstones. It’s just something I will have to deal with if it happens because there’s nothing that can be done about it in the meantime. Luckily, I didn’t experience any pain with my gallstones. I have been told to stop the injections if I suffer any abdominal pain, as they can also cause inflation of the pancreas.

No mention was made of being referred for a psychological assessment. I will contact the hospital to make sure that this wasn’t an error, as my understanding was 90% of patients are referred for a psychological assessment and I am told the waiting list for that is 4 months too.

I left the hospital feeling like I’m one step closer. It’s boosted my motivation, particularly the weight loss injections because there will be follow up appointments to check on my progress. Knowing that I’m going to be held accountable will make it easier to make the right decisions when things are tough.

Weight loss surgery isn’t an easy option. You have to make very big changes for the rest of your life. It completely changes how you eat and how you drink. It’s risky, but then again, being my weight is risky. I saw lots of other patients in the waiting room with leg ulcers, needing walking sticks etc.

If I do nothing, it won’t be long before my physical health deteriorates. I’m young enough to get through this and in five years time I could have a completely different life. It’s not going to be easy but I’m the kind of person that likes a challenge so bring it on, lets do this! One step at a time. Focus on the small things and the big things will take care of themselves.