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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)

  • 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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