How change of commissioning of service can impact its availability in the UK?

Bariatric surgery gives an interesting example of evolution of commissioning of service in the UK. Historically, it was commissioned by the NHS England, which issued a specific commissioning policy, outlining indications for provision of the service. 

Last year the service was partially moved under local commissioning by 209 Clinical Commissioning Groups. This April transition should be completed.

As reported in the open letter from the President of the British Obesity & Metabolic Surgery Society already last year CCGs put certain restrictions in provision of the service:

• "Some of these CCGs say patients must have a body mass index of at least 50 before they will be considered - NHS England and NICE say the threshold should be 40, or 35 if they have other comorbidities, such as diabetes. Two CCGs, Solihull and Wolverhampton, have decided that eligible patients must have a BMI of at least 50 and must also have comorbidities. A couple have demanded that patients must be non-smokers or must sign up to smoking cessation policies before they will be considered."

Bariatric surgery is one of the first examples of transition of commissioning from a national to a local level in England after the reform of the health care system in 2013. This early experience shows that eligibility criteria might be deliberately altered, with limited scientific support.