Why you can’t solve the NHS’s problems by banning smokers and the obese from treatment

Rationing treatment

NHS England has previously been clear that even time-limited bans on particular groups of patients receiving treatment is inconsistent with the NHS constitution.

But now York is rationing surgery on the basis of smoking and obesity – with the support of NHS England.

The evidence is now coming through that this policy is harming patients, that it is discriminatory – and that it is spreading around England. It is time for ministers to take action and stop blaming ‘local decisions’.

On 1 February this year, the Vale of York Clinical Commissioning Group (CCG) started delaying surgery to patients who smoked or had a body mass index of more than 30. The policy was first proposed in September last year, withdrawn then reintroduced in November.

The reason: to delay immediate spend on surgery. However, it is a totally false economy, and although it may delay CCG spend now, in order to meet imposed spending restrictions, the Royal College of Surgeons says that it may actually increase NHS costs if patients develop complications while waiting for surgery. The College has been clear that rationing policies such as those implemented by the Vale of York CCG are unacceptable.

The York CCG’s ability to make rationing decisions comes direct from the 2012 Health and Social Care Act. The duty on the Secretary of State for Health to “provide or secure” the health service was removed from section 1 of the National Health Service Act 2006, and replaced by a duty to make provision for the health service. The list of services that the NHS had to provide—a principle that had been embedded in the NHS since its inception—was also removed, meaning there no longer had to be a universal list of service provision, and that each CCG could determine its own. In other words, it became a complete postcode lottery: where someone lives determines the healthcare they can access.

Jeremy Hunt told the Health Committee on 18 October 2016 that:

“When we hear evidence of rationing happening, we do something about it…we are absolutely determined to give people the clinical care that they need.”

He added:

“When we hear of occasions when we think the wrong choices have been made, when an efficiency saving is proposed that we think would negatively impact on patient care, we step in…”

Now is the time for Hunt to step in.

Under-funded and at risk of being put into ‘special measures’ the Vale of York CCG took the decision to ration surgery for up to a year for those overweight and up to six months for smokers. I was a senior physiotherapist in the NHS and I am all too aware of the risk factors created by people smoking and being overweight, not least when it comes to surgery. All clinicians understand the risk factors, which is why it is so important that money is invested in public health services.

Instead, the Government switched public health back to local authorities and slashed their grants.

In York, the council has completely cut funding for smoking cessation services and for NHS health checks. It also cut the health walks programme, which was a service to help people exercise more and lose weight.

In other words, public health measures to address smoking and weight were cut first, and then patients were denied surgery because they smoked or were overweight.

You really couldn’t make it up.

GPs are now writing to patients to ask them whether they smoke—not that they have a smoking cessation service to refer them to. They say that it is just “for their records”.

But patients who a GP wishes to be considered for surgery now have to fill out a form declaring their smoking and weight status. Does this letter than go to the surgeon to make a clinical assessment of the risks and benefits? No.

Instead the referral is diverted, and the patient is sent a generic letter and a leaflet telling them that they smoke or are overweight and need to change their ways.

As a penalty, they are denied surgery.

The specialist never gets the opportunity to assess the patient and make clinical judgements accordingly.

The Health and Social Care Act was supposedly going to put doctors, not bureaucrats, in charge. Here we have a system where clinicians are being undermined by diktats from bureaucrats; patients and clinicians have no say; and clinical evidence is left wanting.

The generic letter tells those who are obese that they have to lose 10% of their weight or reduce their BMI to under 30, or wait 12 months. Smokers have to stop smoking for eight weeks, or wait six months. They get a leaflet and a referral to a convoluted website. Any public health practitioner would tell you how inappropriate and ineffective this whole system is. There is no real help available.

The Royal College of Surgeons says that denying or significantly delaying access to NHS treatment does not help patients to lose weight or stop smoking.

Now those being denied surgery are paying a heavy price. I have spent much time talking to GPs and surgeons about this matter, as well as to patients. I have also talked to the CCG, which knows that the system is totally wrong, but because it is in a financial hole and NHS England has waved it through, it is just complicit. It is not standing up for patients in York. In fact shockingly it even delayed referrals made before the policy was introduced, so that the first thing that they received was their refusal letter.

So what is the impact on patients? Well, it is devastating. We already know that waiting times for surgery are going up, and delay in itself worsens conditions. It is true that some patients are exempt – those needing urgent care, the removal of a tumour, or trauma surgery. However, if someone requires a joint replacement because they have not walked well for some time due to osteoarthritis, is in pain, and, as a result of not walking, have put on weight, things are very different. With a new joint, they will be back on their feet. A 12-month delay in being referred – 12 months of degeneration, pain and not being able to walk easily – will mean a more complex operation, a patient who needs more physiotherapy and rehab. Bang!—there go all the savings from rationing and more, all at a cost to the patient and a risk that the long-term clinical outcomes will be worse.

The British Orthopaedic Association said:

“There is no clinical, or value for money, justification…Good outcomes can be achieved for patients regardless of whether they smoke or are obese”.

If someone were 20 stone, they would have to drop to 18 stone before having surgery, but if they were 18 stone, they would have to drop to 16 stone 2 lbs. Why is surgery safe at 18 stone in one case, but not the other?

I’ve also seen a patient who was prescribed medication that had a side effect of weight gain. They required surgery and were denied it because of their weight.

I have had a patient who is active and works full time, but is over the weight threshold. She needs surgery to enable her to conceive. She is not young. Surgery is needed now, as recommended by her GP. However, it was denied and could result in her never having a family.

A patient with hypothyroidism, a chronic condition that leads to weight gain, needs surgery for gastrointestinal abnormalities but, despite their condition, will be restricted.

One patient was a very fit body builder, but was refused surgery because of their high BMI. The case for delay has not been evidenced.

We know that there is a strong correlation between smoking and obesity, and social and economic deprivation. As the British Medical Association said, this could also be seen as rationing on the basis of poverty. Those with mental health challenges have a higher propensity to smoke, and those with chronic conditions are more likely to also have elements of depression and possible weight gain. Many people find it difficult to lose weight or give up smoking.

This policy is harming those with co-morbidities. It is creating problems, not solving them. As the Royal College of Surgeons says,

“It risks preventing a patient from seeing a consultant who can advise them on the best form of treatment…Surgery may be needed to help someone lose weight.”

David Haslam, chair of the National Institute for Health and Care Excellence, said that rationing of surgery concerned him. He says that the NICE osteoarthritis guidelines make absolutely clear that decisions should be based on discussions between patients, clinicians and surgeons, and that issues such as smoking, obesity and so on should not be barriers to referral. These are the experts.

The Vale of York CCG has gone down this route, and others are now following, with 34% of CCGs looking to ration on the basis of obesity or smoking. Harrogate and Rural District CCG and East Riding of Yorkshire CCG target smokers and those who are overweight with a six-month delay. Wyre Forest, Redditch and Bromsgrove, and South Worcestershire CCGs ration on the basis of pain impact. South Cheshire CCG requires a BMI of less than 35—not 30—as does Coventry and Rugby CCG. The policy is spreading. Although York is the worst example of rationing, every clinician knows that it is wrong and contravenes their professional duty of care.

Clinical decision making is needed. Patients have to be part of this too. And public health programmes need restoring. The passive approach of the CCGs is setting patients up to fail.

The policy is discriminatory, clinically contraindicated and financially perverse. I would be the first in this House to advocate health optimisation programmes supporting smoking cessation or providing help to improve diet, exercise, wellbeing and lifestyles, but to leave someone in pain or without a child brings our NHS into disrepute.

The rationing of surgery must end. It is time for Jeremy Hunt to step in, as he promised the Health Committee he would.

First published on Open Democracy