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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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  • They are not refusing treatment, they are saying give up smoking first. is that not reasonable?

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  • This is simple. PVD gets better if you stop smoking, to a degree. If you operate on someone and they continue to smoke the 're-plumbing' fails.
    Why bother seeing them in the first place. Just because us GPs have to to see patients who refuse to loook after themselves or fail to follow advice or take treatment, let's stop wasting valuable resources by referring them on.
    They'll be fewer vascular surgeons and their salaries can be diverted to primary care and stop smoking services- ok now I'm being silly!

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  • Vascular disease is a special case because surgical treatment is very expensive, and cannot be compared to inhalers for COPD' which are relatively cheap. However, all referrals should be seen by a consultant, if only to reinforce the advice that most GP's will have been giving for years. Fine, turn down those who fail to comply, and for whom I have little sympathy. A major part of overcoming addiction is seriously wanting to.

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  • whilst the ideal that all patients should be treated as best as possible around their addictions, the simple reality is that there isn't enough money to do so.

    For a conidtion like this, where continued smoking will inevitably lead to deterioration of any intervention, it would be silly to suggest patients should be treated regardless.

    Comparing surgery to inhalers doesn;t make any sense. We give medications for PVD to try and slow onset (eg antiplatelets or statin), same as COPD. We certainly don't go around carrying out lung transplants for COPD pts who smoke do we?

    Morals are great if we as a society can afford them.

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  • So on the above basis should we refuse to consider agnio for ACS? Or non compliant obese type II DM? Why stop with smoking - perhaps we should refuse patients who are over weight, poorly controlled DM, high chole etc. In fact we know one of the bigger influence factor is social status (see qrisk2 for example) as this tends to moderate lifestyle choice and compliance to treatment - should we refuse Tx unless they are middle class or above?

    My point is this - unless they can prove a cost effectiveness on a population, these merits needs to be decided on individual basis. As far as I can see there are no such proof. I'm afraid this blanket ban is non evidence based lazy medicine by doctors who are sitting on too high a horse to be able to what is happening down below.

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  • p.s. If they felt what they were doing is correct, why accept smokers in emergencies? We know outcome of emergency operation is much worse then elective so they should blanket refuse these too (except for amputations I suppose).

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  • There are a number of patients that chose to self neglect ie smoke when they are offered advice and support to stop, diabetics who are non compliant despite education etc. Our job as I see it is to give them informed choice of the consequences. If they choose to ignore this advice especially in this case when continuing to smoke will just re clog the arteries or actually stopping smoking will maybe prevent the need for an operation. As a tax payer I fed up of picking up the bill for people who won't accept responsibility for their lives.

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  • This topic conflates two issues:

    * A judgement of a patient's lifestyle, and the likelihood that their condition was caused by their lifestyle.

    * An evaluation of the efficacy of the treatment.

    It is not ethical to deny patients treatment on the basis of a judgement of how their lifestyle may be responsible for their decision. If we start down that road... It's easy to condemn some lifestyles (smoking, illegal drugs, alcohol); but sedentariness or its opposite, dangerous exercise could be equally blameworthy...

    On the other hand, if a treatment is not likely to be effective due to a patient's ongoing lifestyle, then we are not obliged to offer a useless treatment; and given that resources are tight and treatment has to be rationed, it be provided only if it meets cost-efficacy criteria. It may well be that vascular surgery is unlikely to be effective in smokers, in which case it is not a beneficial treatment, has no cost-efficacy, and should not be offered, at least, not using state funds. This is not a moral judgement on the patient, merely rational use of resources.

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  • I quite agree with you Peter - but I've not seen a population study to this effect to analyse cost-benefit analysis in smokers (we know smokers do less well post vascular op but that's not the same as analysis for cost effectiveness). Unless Mr Reza & co has seen such study with convincing conclusion, I'd say they are passing on a moral judgement.

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  • Only a decade or so it was normal to smoke. We will remember that smoking was allowed in movie theaters, only in England..! Tobacco business was an important one.. Remember also some adverts about the good of menthol cigarettes, good air replacing a WE at the country or in the woods..! And to be a man like the Cow Boy of the advert (he died of lung cancer), you had to smoke! In England, women used to smoke heavily, thanks to all that junk adverts, even in the street, you would not have seen that in another European country..
    I remember having been at a lecture with Prof Guillemet and Prof Soots (France) saying all the stress of the patient if he was refused care.. This is still not possible in France, because there is a severe law about " Non Assistance a personne en danger"' which could conduct to heavy fine and jail if not respected.. So for the Ethic to refuse to examine a person because of anything would be discrimination, against the Human Rights!
    Finance is not the problem! there will be always enough money to build big nuclear submarine boats, but not enough to take care of people??? Or make the tobacco makers responsible and pay individually for consequences of smoking..
    To smoke is a severe addiction, and very difficult to get off.. And it is still authorised.. The GMC should have a word to say about that discrimination of refusing to even see and examine patients!!

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  • And I would add, if an accident arise as a consequence of refusing to see or examine a patient, how a civil tribunal would juge?? Of course all the responsibility would be the consultant's one!
    and our professional insurance would again go up!!!

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  • New agenda to ruin the respect and trust towards drs . Will put off prospective medical students .

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  • We are Scots: it is part of our culture to smoke.

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  • There is nothing stopping the GP referring - we are then medicolegally covered.
    If the surgeon declines to operate due to his personal objection to lifestyle issues, that's his problem to deal with, not ours.
    I don't see where GPs are at risk here.
    For example, I refer lots of fat people for knee replacements and lots of people with partial slipped discs for neurosurgery who may be 50/50 for surgery - it's the specialist's beef what he does with them - frankly after I've done the referral my job is done medicolegally.
    But there is a workload consequence here - if pts are being sent back to us not having TKR for being fat and not having CABG for smoking, they will be straight back to us with ongoing symptoms.

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  • "There is nothing stopping the GP referring - we are then medicolegally covered. "

    This is utterly not true.

    You retain responsibility as the referring doctor - and indeed there have been many cases where the patient has been referred, not turned up to OPD etc, and the GP has been held responsible.

    It is likely that a court would find against you in this kind of situation.

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  • Smoking cessation is a well-known and appropriate management approach in PAD. By refusing to comply, the potential benefits of surgery are impaired, the risk of complications higher.
    Give up smoking or run the risk of losing a limb, dying on the operating table etc!

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  • @ 9.35
    I disagree
    A court of law would hardly find in favour a patient who had been referred, never turned up and never let the GP know!
    Ridiculous.

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  • Took Early Retirement

    Noddy, I hate to tell you, but they WOULD!

    Some years ago, I knew of a doctor who saw a patient who had been to Africa, NOT taken antimalarials, and presented with a fever. The doctor said they were worried re Malaria and asked them to get a blood test asap. Patient came back, or phoned, IIRC 2 days later,, saying not feeling better, blood result not yet back, so GP asked for hepatitis screen too. (Not realizing the patient HADN'T BOTHERED TO GET THE BLOOD TEST DONE.) 2 Days later patient found in a coma by a friend, and died before could be admitted. Cause of death- Cerebral Malaria. Family started to sue and the Defence body said the GP's action had been indefensible as he/she had not CHECKED to make sure the patient had had their blood test. They just paid up.

    I was horrified at their stance.

    Medico-legally, patients have the right to be as feckless and irresponsible as they wish, and we carry the can.

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  • Surgery should be about safe procedures. Being grossly overweight contributes to wearing out the hip joints, so why operate if the cause has not been removed,
    placing the patient at risk during surgery, adding to the nursing care / cost needed, then surgery should be denied. Bariatric surgery should only be offered when the patient has proven he / she has made a real effort to lose weight.
    It is not just about the patients rights, but about safe practice too.

    There is a big difference between given a patient a choice of medication that will not harm them, and risking their life in theatre because they refuse to remove a risk factor.

    If a patient dies in theatre or post op due to the complications of surgery caused by their lifestyle, see how long it takes for the relatives mention compensation!

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  • A difficult diabetic saw her consultant who told her losefatexercise and stop her meds not increase treatment

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  • Neurosurgeons refuse to accept head injury patients of fast car drivers, sportbike riders, horse riders ...etc. You get my drift. The justification behind such a policy would be similar to barring smokers from being offered certain therapeutic interventions. The real reason is that damage sustained from such activities is self inflicted. So a moral judgement is being made and the condition the patient has is self inflicted and is punishment for their perceived indulgences. This attitude is veiled behind terms such as that outcomes of therapy would be worse compared to say (righteous) non smokers.

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  • Along all the discussion, the main question has been forgotten: "should a consultant refuse TO SEE a patient because of a wrong lifestyle"???
    The response must be NO!!!
    The GMC should do his job by sanctioning the consultant who would refuse!!!
    If he does not, the Daily Mail, RT etc..., would jump on that case!!
    First the patient is not responsible of having started to smoke, and fall into that very strong addiction... It still is a profitable authorised business...and a few time ago everything was done for the person to start smoking! Like free tobacco to soldiers..adverts etc..
    Secondly, if he suffers from pain, or his life is in danger, everything must be done to help him...
    Thirdly, the patient is not a medical professional and his fundamental human right is to ask and to be seen by a doctor, and if the dr feels the need to get a consultant advice, this cannot be refused, and has to be done in a correct delay if necessary.
    The funding of Health is not the problem of the doctors. This is a political choice between public spending things, a choice between the construction of a nuclear submarine and a sufficient number of consultants/hospital beds in England..
    The only first obligation for the doctor is to deliver the best quality and up to date medicine, without discrimination of any kind, race, religion, nationality, or lifestyle.. Funding comes secondly!!
    Dr Jean-Marie Sandor

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