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Rationing disguised as health promotion?

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