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At the heart of general practice since 1960

Should GPs ration by lifestyle? No - this is rationing dressed up as science

Reports in Pulse that PCTs and emerging clinical commissioning groups are ‘rationing care' for obese patients and smokers gained widespread coverage in the mainstream media. A policy introduced in Hertfordshire earlier this year was cited as an example, and some commentators have cried ‘discrimination' and told us our approach has no place in today's NHS.
The other side : We're not picking on patients to save cash

What is it that we enjoy about general practice? Ask any of your colleagues and the reply is almost invariably that it is the continuing clinical relationship with a defined group of patients that is the cornerstone of job satisfaction.

Yes, there are others who are enthusiastic about non-clinical roles, but when push comes to shove it is the long-term relationship with patients that is our raison d'être. But that relationship is under threat by the recent imposition of lifestyle-based rationing.

In Hertfordshire, patients are restricted from accessing surgery of any kind if they smoke and orthopaedic surgery is restricted to those who qualify with an acceptable BMI. This ‘fat and fags policy' now seems to be rapidly spreading to other areas.

To confuse matters further, the BMI deemed acceptable just to be able to see the consultant depends on where you live and whether you have metabolic syndrome.

Our clinical commissioning group – which uniquely consists of just our practice – cannot and does not accept this as a basis of rationing and rejects this policy.

This is rationing dressed up as science. We are sensitised to pharmaceutical companies producing literature in which graphs always seem to show that their product offers salvation, and we are aware of publication bias and the omission of negative trials.

Yet the whole pseudoscience behind lifestyle rationing is riddled with the selection bias and omissions that PCT pharmaceutical advisers have been decrying for decades.

This form of rationing disqualifies a subset of the population due to aspects of their lifestyle. Hip and knee replacement are some of the most effective procedures in terms of quality of life, yet they are to be denied to the ‘fat and fags' group.

Where does this go next? Will we deny IVF to those who have had pelvic inflammatory disease because of its association with sexual promiscuity? Will we restrict access to healthcare on the basis of diet, alcohol consumption, genetics or sex? This is not like denying vascular surgery to a smoker, which is based on overwhelming evidence. This is trying to justify rationing and reduce referral rates.

My Hertfordshire colleagues are driven to distraction filling in complex forms for every referral. At Red House CCG we dictate a referral letter in front of the patient – job done. All other Hertfordshire GPs have to supply an array of data including BMI, smoking history, evidence of smoking intervention, Oxford Hip scores and X-ray results before an appointment to see a specialist will be granted. Rationing by paperwork is a brilliant device, because when you know that you have to do a major project on every referral, you do your damn best not to refer! 

There is an alternative. As both a practice and CCG we aim to make every referral a necessary referral and ensure that we have explored all possible avenues.

The focus is on the individual need of the individual patient, whatever their BMI or smoking status. Our referral and prescribing rates are well within target and we work hard as a team to keep them there.

The weight-loss management programme at our practice has been a success, and from my days as a junior doctor protesting at cigarette-sponsored sporting events no one can ever doubt my views on smoking.

But our most important asset is our patients' trust – and that rests on their faith that we are acting in their best interests. If we lose it, we are only another apparatchik in the vast organisation of the NHS.

If we safeguard it we will maintain our privileged place in the lives of our patients – and can be a catalyst to help change their lifestyle.

Dr Michael Ingram is chair of Red House CCG in Hertfordshire

Read the other side of the debate here

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