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Should GPs ration by lifestyle? Yes – we’re not picking on patients to save cash

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.


Let's get the facts straight. What we are doing is asking people who are seriously overweight to lose some of that weight before being booked in for routine surgery. And we are asking smokers to have a session with a stop-smoking adviser beforehand.

No patient in Hertfordshire is refused surgery because of their weight or because they smoke, if their clinical condition tells us they need it. GPs can make a case for a seriously overweight patient being treated for routine surgery as an exception, even if the patient hasn't lost weight. A patient's need will always be the most important consideration. We introduced this policy for sound clinical reasons, not to reduce spending. The vast majority of patients will still have their surgery – but now they will be healthier when they do.

There is incontrovertible clinical evidence that obese patients and smokers face significantly increased dangers from having a general anaesthetic, including developing respiratory and cardiac problems and recovering more slowly after operations.

Doctors have always talked to patients about the risks of undergoing surgery – but we are making those conversations more robust, giving each patient the opportunity to be in the best possible health when they have an operation.

Facing a serious event, such as surgery, can be a powerful prompt for people to change their lifestyles.

We have an opportunity to have a significant and positive impact on people's health. Why would we not want to grab this chance?

Yes, having conversations with patients about being overweight is uncomfortable. Weight is a sensitive area for all of us. But it is our responsibility to talk frankly with people. The approach we are taking in Hertfordshire is sometimes opposed with the assertion that every taxpayer has a right to treatment under the NHS – and of course they do. But clinicians have a responsibility to provide the best treatment for patients as individuals, taking full account of their current state of health. That is exactly what we are doing.

We are acutely aware that poorer sections of society suffer most from the effects of obesity and smoking. This policy can go some way towards achieving the aim we all share – to reduce health inequalities.

Our current policy is evidence based. We looked at the results of a pilot we ran last year, for people who needed hip and knee surgery. Preliminary analysis shows the majority of people who were asked to lose weight reached their target. For some, the weight loss improved symptoms so much they chose not to have their joints replaced. Attendance at stop-smoking sessions has doubled.

People in Hertfordshire haven't been shy about telling us what they think of this approach either. We have had support from local people, including those who themselves have a weight problem, and some have even urged GPs to take firmer action to help stem the tide of obesity.

We reject completely the accusation that we are judging people's choices, setting apart the ‘undeserving' from the ‘deserving' or picking and choosing who we treat. As any GP would, we are doing what we can to improve public and individual health.

Dr Nicolas Small is chair of Herts Valleys CCG; Dr Tony Kostick is chair of East and North Hertfordshire CCG; Dr Mike Edwards is medical director of NHS Hertfordshire

Read the other side of the debate here