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Consultants refuse to accept GP referrals for smokers

Consultants at one hospital have announced that they will refuse to accept GP referrals of patients who smoke.

Vascular surgeons from Edinburgh Royal Infirmary have defended their right to demand that patients stop smoking before accessing certain kinds of treatment.   

The hospital, part of NHS Lothian, has argued that medical intervention for vascular disease could be avoided altogether if patients stopped smoking and adapted to healthier lifestyles.

Mr Zahid Reza, a consultant vascular surgeon at ERI, said that his clinic was refusing to accept GP referrals for patients who continued to smoke, unless it was an emergency.

He told the Scotsman: ‘Evidence shows that they would not do well with the treatment. In around 80% of cases, a smoker’s condition will improve just simply by stopping smoking and making other lifestyle changes.

‘Some patients have written to their MP demanding to see a consultant. I have written back to the MP to explain our position.’

NHS Lothian have denied the existence of a ‘blanket ban’ on refusing referrals, saying that each patient is treated on a case-by-case basis. However, Dr David Farquharson, medical director at NHS Lothian, said that some kinds of surgery had a lower chance of success, and that the chances of complications arising during surgery were higher for patients who smoke.

He said: ‘The best option can actually be to refer a patient into smoking cessation, fitness and diet intervention programmes to help them change their lifestyle, which will in turn improve their condition and if necessary the outcome of any medical intervention.’

But patient groups have attacked the decision, describing it as ‘shocking’.

Dr Jean Turner, a former GP who heads up the Scotland Patients Association, said that she was ‘extremely disappointed’.

She added: ‘You should not refuse to see anybody and certainly not penalise patients who are smoking. It is very God-like and highly unfair to refuse to see people referred from general practitioners.

‘If I was a GP I would be very angry. It’s not for a doctor to make a judgment. Doctors are there to see if they can help and relieve symptoms.’

A Scottish Government health spokeswoman said that a blanket ban on surgery for smokers was ‘not acceptable’ and denied that either the Government or NHS Lothian had proposed such a ban.

She added: ‘Smoking is never good for you. Patients who continue to smoke need to think very carefully about the increased risks involved, if surgery is being considered as a treatment option.’

Readers' comments (42)

  • I think its fair enough.

    We dont give out liver transplants for alcoholics, even though we could - and that "can help and relieve symptoms".

    I think we as a profession are far too soft on people who clearly need a dose of harsh reality.

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  • Totally agree with the ban.I have lost track of the number of patients with severe vascular disease including amputees who refuse to stop smoking.Not only does this totally nullify any benefits of treatment it greatly increases the burden on the taxpayer.When you have a free at point of delivery service like the NHS patients become irresponsible and expect that everything is their God given right.

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  • Entirely agree. And would be happy to tell this to my patients given the reasoning for it. Good job as it looks like I will have to have this conversation soon. Work in Edinburgh.

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  • "Next we will refuse to perform bariatric surgery on those who eat too much...."

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  • I think we need to take a step back and consider what our role is. Our role is to know which interventions are available to our patients, give them the choices, tell them the pros and cons for each treatment and guide them in their choice.

    But it is their choice.

    If I want someone to have a TKR and they choose analgesia instead - it is not my place to refuse naproxen because it is different to my opinion.

    Similarly if I think a patient should stop smoking and have inhalers for COPD, but they insist on continuing to smoke - it is their choice - it does not exclude them from having an inhaler.

    The same should apply to vascular surgery. It is important to make sure patients are aware of the differences in risk/ benefit balance between smokers and non-smoker and provide them with the assistance to stop smoking. But it is only acceptable to ban them from treatment if that balance becomes inappropriate.

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  • understand the cosultants frustration..but we are not here dealing with a lifestyle choice but an addiction that not all can overcome.
    his stance is in my view misguided and unethical..nhs treats other addicts..addictions are a medical condition with multifactorial causes.
    he should do his job and help all the best he can..of course results will be much poorer for those who can't/won't stop..but drs spend most of their time ameliorating hopeless cases..yes nhs costs may be higher but pension costs will be much lower than someone lingering on for years with chronic illness.

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  • Entirely agree with the last post.

    Whilst patient must accept they must be responsible for their actions, refusing to see them based on their choice is irresponsible and neglectful. I'm astonished by the self righteous and unholistic care Mr Reza is providing up north.

    I'd also question the professional pride of the GPs who accept such ban. I don't see myself any less important then the specialists, and I would not refuse to treat a patient just because they are unable to manage their risk factors. Why would the specialists act any differently? Do they have different law in the hospital?

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  • Thin edge, as mentioned above we treat other forms of addiction and certainly don't expect anything like 100% compliance. Understand the frustrations but so many other specialities could stop treatment because of inability to change lifestyle choices.

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  • I think a total ban is unethical and arrogant.
    However, an initial ban while addiction treatment is given is reasonable because it would give the patient an incentive to really tackle their addiction.
    My mother in law was a major nicotine addict when our first child was born. I told her that if she wanted to spend any time with her she had to stop smoking. She did, instantly, and has never smoked in the 27 years since. I am certain that if I had tolerated the smoking she would still be at it and she is very grateful indeed. ( She wasn't at the time I can assure you!)

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  • I think we are somewhat missing the point. If a Consultant wants to decline offering an operation after seeing a patient because he/she thinks it won't work, that's their choice.

    The story seems to suggest that the referral itself is being declined. Medicolegally, this puts the GP in a very difficult situation because, yet again, the risk is being passed back to individual GPs. If a patient develops an acutely ischaemic leg after having a referral declined, a court would likely find the GP most likely to blame (perhaps the consultant partly responsible also).

    Why are we so keen to take on this risk - we're paying for it through our defence premiums!

    If they want to see the patient and then decline, no problem by me.

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  • We don't need to refuse to treat people who self harm with activities like smoking and drinking, but I approve completely of refusing to do it on the NHS. I do not pay taxes to support people trying to kill themselves. If they want that they can go private and pay for it themselves. So well done to the consultants, now lets move on, make it throughout the UK and make people face up to the responsibilities of their own actions and stop expecting the rest of us to pay for their selfish misbehaviour.

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  • Pranged your knee ski-ing?
    Fractured your femur on a donorcycle?
    Where will it stop....

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  • Bravo, to the vascular surgeon. Brave decision indeed. Bt it would have been even better if they had announced conditional acceptance of referral with three months to try give up. They have not turned down emergencies anyway, so what's the fuss!?

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  • That's the answer then. Grandchildren.

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  • I would kindly draw the attention of Dr Turner and colleagues to 'Cigarette smoking and musculoskeltal disorders', a review article by Abate M et al in Muscles, Ligaments and Tendons Journal 2013; 3 (2): 63-69 as well as Vo N et al 'Differential effects of nicotine and tobacco smoke condensate on human annulus fibrosus cell metabolism. J Orthop Res 2011; 29(10):1585-1591.
    Its not the question of surgery/intervention or not- its the best outcomes later. Where do we draw a line in managing and treating patients if they continue to ignore advice and recommendations?

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  • A previous blogger had the answer. Have grandchildren!

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  • "so what's the fuss!?"

    The fuss is that the hospital has transferred the medicolegal responsibility and risk to the GP. If a Consultant surgeon doesn't want to operate after seeing the patient, that's fine.

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  • Indeed from a general point of view it seems a bit too much to say a total ban is being imposed. But read between the lines - "emergencies would still be accepted". Maybe the total ban is not as total as it sounds. Indeed a smoker undergoing any form of surgery is putting him/herself at risk of serious complications. I think it would be very useful to highlight this to all smokers and have a direct referral pathway to the stop smoking clinic. Being refused surgery and continuing to smoke is not really an option to consider at all.

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  • There is a certain irony in members of a privileged social group reinforcing the already well demarcated health inequalities between 'classes'. Smoking is the single greatest killer among the less well off. To then suggest that particular groups of patients should not access certain treatments because they smoke seems to compound the problem. It is also hypocritical because similar judgements don't seem to have been applied to heavy drinkers. I wonder why.

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  • So they would refuse to treat a patient to prevent further damage but would happily accept patient when it's deteriorated enough to have become critical as an emergency (and likely more harmful to patient)?

    That's alright then!

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