Following the rise in popularity of medical tourism and long NHS waiting lists, patients are seeking more medical treatment abroad. Julie Baylis, Case Manager at Medical Protection, explores the recent trend of patients seeking bariatric surgery overseas and returning to the UK for follow up care

News of NHS patients travelling abroad for bariatric surgery has been widely reported in the media, with some articles warning of the risks and uncertainty of follow up care on the NHS on their return to the UK. Shorter waiting times and cut-price procedures abroad are becoming more appealing to those who do not meet the meticulous criteria for NHS weight loss surgery or to those who are not willing to pay the private fees associated with such procedures in the UK. With more patients travelling abroad for weight loss surgery, it is no surprise that GPs are facing an influx of follow-up monitoring requests and are uncertain of their responsibilities.

Case scenario

“I am a GP and recently my colleagues and I have received several requests to provide aftercare and follow up monitoring to patients who are planning to, or who have already undergone, gastric bypasses or gastric sleeve procedures abroad.

“For one patient, we received correspondence directly from a private clinic abroad, asking the practice to make a number of arrangements, including carrying out regular blood tests to review vitamin and mineral levels, undertaking physical health checks and arranging ultrasound scans. Whilst this particular clinic did indicate the blood tests that were required, many clinics do not detail the specific requirements for blood monitoring.

“We understand that aftercare is key to achieving a successful outcome for these patients; however we do not feel it is within our remit as GPs to interpret scans or blood results post-bariatric surgery. We feel that without specialist knowledge, we cannot provide the safe follow-up care package that NICE guidance stipulates. We do not believe that we have the necessary expertise to provide appropriate aftercare to these patients.

“Given that these procedures are carried out abroad privately, can these patients be signposted and directed to obtain private follow-up care within the UK?”

It is understandable that GPs may be concerned and have questions regarding their responsibilities when faced with patients who have undergone procedures abroad.

NICE guidance

NICE, within their Obesity: clinical assessment and management guidance, recognises that patients who have undergone bariatric surgery should receive a follow-up care package within the “bariatric service for a minimum of two years”, which should include “monitoring nutritional intake (including protein and vitamins) and mineral deficiencies, monitoring for comorbidities, medication review, dietary and nutritional assessment, advice and support, physical activity advice and support and psychological support tailored to the individual”. Within this guidance it is recognised that “for the first two years after surgery, follow up appointments are likely to be with a dietician or bariatric physician”, after which follow-up appointments are likely to be with a “dietitian or GP within a locally-agreed shared-care protocol”.

In a scenario where the patient has yet to undergo the bariatric procedure abroad, a general practitioner may wish to have a discussion with the patient regarding their request for aftercare and specified blood monitoring in conjunction with the services that are available within the UK, both in the NHS or the private sector. In this scenario it would be prudent to discuss their plans with the patient, along with the associated risks of undertaking treatment abroad, language barriers and how aftercare could be provided on their return to the UK.

Regardless of where the procedure was carried out, overseas or within the NHS or privately in the UK, the need for appropriate aftercare, monitoring and follow-up remains.

Competence

As the GMC states in Good Medical Practice, doctors must “make the care of the patient their first concern”. The patient still has the same expectation that they will be assessed and provided clinical care as any other patient. However, the GMC highlights that doctors must “recognise and work within the limits of your competence”.

The GMC in their guidelines also state that “in providing clinical care you must; a) prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs and b) provide effective treatments based on the best available evidence”.

As highlighted by the GMC, a GP must work within their expertise and act in accordance with their clinical judgement. Of note, there is no obligation for a clinician to act outwith their area of competence and expertise, but it would be expected that a GP would be aware of the importance of safe aftercare and the impact this may have on a patient’s health if they do not receive appropriate aftercare post-surgery. Therefore, the GP must consider whether specific clinical monitoring could be provided by them or whether the patient should be referred to secondary care.

In such circumstances where the clinician feels it is not within their field of expertise, it would be prudent to seek advice from the appropriate colleagues and consider appropriate referrals where required.

Shared care

In most situations in general practice, it is reasonable to rely on the specialist opinion of a secondary care doctor to be satisfied that the treatment is in the patient’s interests. However this reliance is not absolute and understandably concern may arise when the GP is not familiar with the overseas clinic or its doctors and has not been provided with the reassurance that the treatment is the most suitable for the patient.

The GMC provides guidance on continuity and co-ordination of care, advising that clinicians “must contribute to the safe transfer of patients between healthcare providers and between health and social care providers. This means that clinicians must; a) share all relevant information with colleagues involved in your patients’ care within and outside the team, including when you hand over care as you go off duty, and when you delegate care or refer patients to other health or social care providers and b) check, where practical, that a named clinician or team has taken over responsibility when your role in providing a patient’s care has ended. This may be particularly important for patients with impaired capacity or who are vulnerable for other reasons”.

The GMC state that when clinicians “do not provide their patients’ care themselves, for example when they are off duty, or delegate the care of a patient to a colleague, the clinician must be satisfied that the person providing care has the appropriate qualifications, skills and experience to provide safe care for the patient”.

A difficulty could arise in the context of shared care agreements with clinics overseas due to differing regulatory requirements, differences in guidelines and clinical standards and language barriers. With this in mind, a GP may wish to seek advice from a UK bariatric specialist in this scenario.

If a GP were to contemplate entering into any arrangement for shared care with the overseas clinic, it would be essential to seek details from the clinic about the surgeon and or team.

Conclusion

Ultimately the GP would be required to assess their level of expertise and consider whether they will agree to provide follow up and monitoring of blood tests for a post-bariatric surgery patient on their return from overseas. If a GP were to agree to monitor the patient’s blood results and feel it is within their field of expertise, it would be essential for patient safety reasons to have a clear understanding of roles and responsibilities set out in writing and make it clear to the patient that they are not an expert in this field.

It would be advisable for the GP to liaise with their local secondary care or bariatric services within the commissioning area to consider all the available options in relation to follow-up care.

It is advisable for GPs to document all discussions with patients, as well as the rationale for the care provided, including any decision to refer the patient to secondary care.

For tailored advice regarding bariatric surgery and GP follow-up care please contact Medical Protection.