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| The NHS must treat smokers and the obese fairly | |
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| One in three areas in England is denying or delaying surgery to patients who are obese or who smoke. That’s the stark finding of a new report by the Royal College of Surgeons. | One in three areas in England is denying or delaying surgery to patients who are obese or who smoke. That’s the stark finding of a new report by the Royal College of Surgeons. |
| Some may think it appropriate to deny treatment to people who overeat or smoke in a cash-strapped NHS, but as surgeons we think it wrong to have a blanket ban on surgery based on such criteria. Targeting patient groups risks unfairly isolating them and undermining the fundamental NHS principle to treat all patients freely at the point of need regardless of their background or lifestyle. | Some may think it appropriate to deny treatment to people who overeat or smoke in a cash-strapped NHS, but as surgeons we think it wrong to have a blanket ban on surgery based on such criteria. Targeting patient groups risks unfairly isolating them and undermining the fundamental NHS principle to treat all patients freely at the point of need regardless of their background or lifestyle. |
| During my career as an orthopaedic surgeon, I have met many smokers and obese patients. In such cases, I strongly encourage patients who are evidently risking ill health to lose weight and stop smoking. Ensuring patients are aware of the risks of unhealthy lifestyles should be a role for all doctors who come into contact with patients. In some cases, we know that successfully losing weight has changed patients’ symptoms such that they no longer need hip or knee operations, because their pain had been exacerbated by their additional weight. | During my career as an orthopaedic surgeon, I have met many smokers and obese patients. In such cases, I strongly encourage patients who are evidently risking ill health to lose weight and stop smoking. Ensuring patients are aware of the risks of unhealthy lifestyles should be a role for all doctors who come into contact with patients. In some cases, we know that successfully losing weight has changed patients’ symptoms such that they no longer need hip or knee operations, because their pain had been exacerbated by their additional weight. |
| Many patients are willing to engage and use their resolve to improve their overall health, but it can be very difficult to lose weight. That’s why neither NICE nor surgical experts recommend a blanket ban on surgical procedures purely based on someone’s weight or smoking status. Decisions should be made in conversation between patients and their doctors. | Many patients are willing to engage and use their resolve to improve their overall health, but it can be very difficult to lose weight. That’s why neither NICE nor surgical experts recommend a blanket ban on surgical procedures purely based on someone’s weight or smoking status. Decisions should be made in conversation between patients and their doctors. |
| The financial pressures facing the NHS provide the backdrop to policies that are being implemented by clinical commissioning groups (CCGs). It is difficult to prove that CCGs are primarily seeking to ban surgery in this group to save money; they certainly wouldn’t admit it. Some have provided clinical justification, often citing improved outcomes for patients who don’t smoke or who have an improved BMI. However, their reasoning is often not consistent with national guidance developed by NICE or the Royal College of Surgeons. Undoubtedly a patient with a high BMI may still have an overall positive outcome from surgery. | The financial pressures facing the NHS provide the backdrop to policies that are being implemented by clinical commissioning groups (CCGs). It is difficult to prove that CCGs are primarily seeking to ban surgery in this group to save money; they certainly wouldn’t admit it. Some have provided clinical justification, often citing improved outcomes for patients who don’t smoke or who have an improved BMI. However, their reasoning is often not consistent with national guidance developed by NICE or the Royal College of Surgeons. Undoubtedly a patient with a high BMI may still have an overall positive outcome from surgery. |
| It is unlikely to be a coincidence that some of the areas facing the greatest financial pressures are also restricting access to treatment. My fear is that these patient groups are becoming soft targets for NHS savings, possibly justified by a view that these patients are more likely to have “inflicted” the problem on themselves due to their poor health choices. If we applied the same logic to other groups then we might end up restricting quite a bit of treatment on the NHS. Would we deny treatment to binge drinkers who repeatedly end up in A&E? What about people who play dangerous sports and end up requiring physiotherapy and/or surgery? | It is unlikely to be a coincidence that some of the areas facing the greatest financial pressures are also restricting access to treatment. My fear is that these patient groups are becoming soft targets for NHS savings, possibly justified by a view that these patients are more likely to have “inflicted” the problem on themselves due to their poor health choices. If we applied the same logic to other groups then we might end up restricting quite a bit of treatment on the NHS. Would we deny treatment to binge drinkers who repeatedly end up in A&E? What about people who play dangerous sports and end up requiring physiotherapy and/or surgery? |
| The important issue is one of equity. The public may rightly wonder whether it is fair that overweight people in some parts of the country can access surgery, but in other regions that same treatment is denied. The debate as to the “national” offer will rage on. | The important issue is one of equity. The public may rightly wonder whether it is fair that overweight people in some parts of the country can access surgery, but in other regions that same treatment is denied. The debate as to the “national” offer will rage on. |
| As the spotlight focuses on improving NHS finances, there will be a temptation to restrict access further for those groups who are perceived to have only themselves to blame. In other words, commissioners might try to save money by cutting provision for patients for whom the wider public has less sympathy. | As the spotlight focuses on improving NHS finances, there will be a temptation to restrict access further for those groups who are perceived to have only themselves to blame. In other words, commissioners might try to save money by cutting provision for patients for whom the wider public has less sympathy. |
| That’s why it’s time for a much more honest public debate. What should and shouldn’t the NHS provide and how much are taxpayers prepared to pay for it? According to OECD figures, the UK spends about 8-9% of GDP on health – below that of a number of comparable western countries. While this is an imperfect measure, it suggests there may certainly be room for improvement. A cross-party commission should examine the issues and make recommendations to the government. It should not be afraid to call for changes in funding or consider which services the NHS can’t afford to provide within current funding levels. This is not about another expensive talking shop. | That’s why it’s time for a much more honest public debate. What should and shouldn’t the NHS provide and how much are taxpayers prepared to pay for it? According to OECD figures, the UK spends about 8-9% of GDP on health – below that of a number of comparable western countries. While this is an imperfect measure, it suggests there may certainly be room for improvement. A cross-party commission should examine the issues and make recommendations to the government. It should not be afraid to call for changes in funding or consider which services the NHS can’t afford to provide within current funding levels. This is not about another expensive talking shop. |
| Without a degree of consensus among the public and politicians, there is a risk that serious proposals to make the NHS more sustainable will not get off the ground. If there are moves to cut the level of service the NHS can realistically provide without a consensus, decision-makers may be criticised for a creeping “privatisation of the NHS”. | Without a degree of consensus among the public and politicians, there is a risk that serious proposals to make the NHS more sustainable will not get off the ground. If there are moves to cut the level of service the NHS can realistically provide without a consensus, decision-makers may be criticised for a creeping “privatisation of the NHS”. |
| Well-informed, open and logical debate should ensure that decisions made locally will reflect a truly National Health Service. | Well-informed, open and logical debate should ensure that decisions made locally will reflect a truly National Health Service. |
| Clare Marx is president of the Royal College of Surgeons | Clare Marx is president of the Royal College of Surgeons |