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GPs go forth

Rationing disguised as health promotion?

Dr David Turner

How does an obese smoker get knee surgery in 2020?

No, this is not the build up to an elaborate joke, but a genuine question.

Our CCG sent a letter on 23rd December (am I paranoid, or is there a pattern establishing itself here of burying bad news in the Christmas holidays?) stating that from 1st January 2020, all new referrals for non-urgent elective surgery procedures that require prior approval would be refused if a patient is a smoker and/or has a BMI over 30, until they stop smoking and lose weight.

From 1st April 2020, this will apply to all other elective procedures (under general anaesthesia, epidural or spinal anaesthesia) that do not need prior approval.

Patients can be referred to a surgeon for assessment, but if found to be obese and/or a smoker, will be sent back to their GP for lifestyle advice and in the case of smokers, will need a certificate showing their carbon monoxide level, to prove they have stopped smoking before they can be re-referred to the surgeon.

Part of me thinks this is a good idea. Of course we should be doing all we can to help patients lose weight and stop smoking, but the other part of me knows damn well that the sort of patients who need knee and hip surgery most are the ones who will never be able to lose weight, and certainly not while they have a dodgy hip or knee.

I very much doubt private hospitals will be enforcing such a policy

This policy will, of course, worsen health inequalities, as I very much doubt private hospitals will be enforcing such a policy, meaning the overweight smokers who can afford it will just pay for their surgery.

There's something a little bit patronising about having to get a certificate from the GP to prove you are no longer a naughty smoker, but putting that aside for a moment, and the extra paperwork this will generate for GPs, what concerns me most is the fact that it will be us who have to bear the brunt of patients’ wrath when they are refused surgery because of their lifestyle choices.

You can hear it now: ‘Who does that surgeon think they are telling me I’m fat, have they looked in the mirror recently? I want a second opinion.’

The very cynical side of me, and, to be honest, the largest part, wonders why this policy is suddenly being enacted now. After all, it's not as if some groundbreaking research has just been published, showing overnight that smokers recover less well from surgery then thin non-smokers.

No, this is about nothing more than rationing, and watch this space, because there's a lot more to come our way.

Dr David Turner is a GP in North West London

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Readers' comments (17)

  • One of the Black Mirror episodes describes a world where money is earned by cycling on a Pelaton style electronic bike all day. In this world the overweight are marginalised and mocked.
    This is the end point of state socialism - the state determining who is ‘deserving’ of the money stolen as tax and funding mechanisms like the NHS crowding out alternatives except for the mega rich.

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  • ‘This policy will, of course, worsen health inequalities“

    You hit the nail on the head there.

    This is the inevitable consequence of a socialist government acting as some sort of social policeman, deciding who gets this treatment or that treatment depending on which rules that, yes you guessed it, government, decides to set at any given point in time. The goal posts can move as government sees fit, which basically means how much money government can expect to steal from the taxpayer in any given year.

    This socialist perversion has 2 inevitable consequences that we have seen time and time again:

    1. It takes away people’s individual liberty of choice in healthcare by making the majority of the population reliant and dependent on their local state “provider” for their health needs. If that provider tells the patient to bugger off because they’re a smoker then that person is pretty much stuffed
    2. It worsens health outcomes

    i.e. it worsens the problem it was supposedly intended to solve in the first place.

    The great government con continues.

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  • ‘This policy will, of course, worsen health inequalities“

    - But it is fair. Those who have strived, or whose parents/family have strived, and who can afford it, get to enjoy the benefits of striving. And I'm sure life is unfair, that some will suffer undeserving misfortune. And those who have fostered strong familial and friendship bonds will have more support to rely on, than those who haven't. And there are some of us, who are even willing to consider/choose to help strangers directly. The state compelled and delivery of redistribution is the most inefficient, and I would argue, even immoral.

    - When you talk about health inequality, you mean equity/outcome. What is unfair is the taxing of a working class responsible healthy non-smoking bus driver, to pay for the rich overweight smoker's new knee. What happened to you reap what you sow, a concept we teach our kids (or at least I try for mine)?

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  • Re: ‘What is unfair is the taxing of a working class responsible healthy non-smoking bus driver, to pay for the rich overweight smoker's new knee. What happened to you reap what you sow, a concept we teach our kids (or at least I try for mine)?’

    Perhaps overweight smokers should get a tax rebate then as they’re not going to benefit from the NHS as much as fit people?

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  • I heard Rebecca Long-Bailey say " we must be better salesmen for socialism"
    And, pretty sure she used the sexist damned phrase "salesMAN"

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  • If patient wants a second opinion, they should bring photo of the surgeon with them to GP, and also the surgeon's Height, weight, and carbon monoxide printout!
    I'd be happy to give the second opinion, carefully worded of course, to avoid any criticism of my colleagues excess BMI!

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  • doctordog.

    What a great idea.
    Leaflets and posters need to be available for all patients who fall foul of these rules.
    On these documents will be the names of the individuals at the CCG who are responsible, with contact telephone and mail addresses for complaints.

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  • There is some rationale behind it. A family member has a knee problem and previously had an arthroscopy but this time was told would have to lose weight before considered. BMI 34. They went to the gym and changed their diet and lost some weight but more importantly the Gym work strengthened their knee and in the end there was no need for the surgery. They used to go down stairs using the good leg for each step now they go down easily using both. Their mantra was do this not to have surgery but to avoid surgery. To easily surgeons step in to fix things which do not need their fixing and sometimes are made worse. The surgeons mantra is can we fix it yes we can- but sometimes and with some procedures they can’t or they make it worse.
    While having said all this the Motivation for weight and smoking thing is a rationing but it will have the side effect of improving the health of some patients.
    We need to get to a state where the surgeons are more honest with patients and do a good job of explaining there are better alternatives but which might require some effort. At the moment their clinic is judged on conversion rates. Converting a consult to an operation. Perhaps the lower the conversion rate the better the surgeon.

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  • Why are we laying the blame on the surgeons? They are only passing on the message from their employers who in turn are passing on the rules laid down by the commissioners. Rather bad form to be criticising our hospital colleagues when they don’t deserve it.
    BMI 30 isn’t that fat- or possibly isn’t fat at all if you happen to be a stocky rugby player type or a gym junkie.
    Smokers are a possible health and safety issue for the poor anaesthetists breathing out Contaminated air from their lungs. Well anything is possible and if you need a justification to discriminate against these social pariahs it seems a reasonable enough excuse.

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  • Just an observation here, call this socialism or not, it is the NANNY state in my view, but also it is occurring under Tory not Socialist political administrations.

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