NHS ‘ban’ is a health warning

Question of ethics?: Health chiefs in the Vale of York have suggested restrictions on elective surgery for smokers and the overweight, sparking outcry. (PA).
Question of ethics?: Health chiefs in the Vale of York have suggested restrictions on elective surgery for smokers and the overweight, sparking outcry. (PA).
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The Government denies obese patients and smokers are being banned from having surgery. But who is affected and what does it say about the state of the NHS? Chris Bond reports.

The news that obese people and smokers in Yorkshire face possible restrictions on having surgery has sparked widespread consternation. The restrictions, brought in by NHS Vale of York Clinical Commissioning Group (CCG), mean overweight patients will have to lose 10 per cent of their weight before surgery, while smokers face a possible six-month delay unless they quit.

This isn’t the first time that such measures have been mooted. The CCG, which serves a population of more than 351,000 in areas including York, Selby and Tadcaster, proposed the surgery delay in September, but it was put on hold following a public outcry.

It said only elective surgery for non-life threatening procedures, such as hip and knee operations, would be affected, and NHS England has now approved the plan which will come into effect in January.

However, it has come in for heavy criticism. The Royal College of Surgeons (RCS) was quick to condemn the move with its president Clare Marx saying she thought the CCG’s decision was “frankly shocking”, adding: “We think all patients should be treated according to their symptoms”.

Dr Shaun O’Connell, a clinical lead at Vale of York CCG, denied reports the measures amounted to a ban on surgery and claimed the change would bring patients the “best possible health outcomes in the long term” while at the same time helping to protect finances.

Downing Street waded into the row yesterday afternoon insisting that patients were not being denied operations by the CCG. “The Vale of York Clinical Commissioning Group has been very clear that there is no ban and no blanket policy,” said the Number 10 spokesman.

“People who fail to meet certain criteria will not be denied their operation. Clinicians will give advice to patients and it is right that they do so. Procedures for patients will be based on the best interests of the patient’s health. They won’t be denied the operation. What is important is that the patients receive the appropriate clinical advice and that is what is taking place at the Vale of York CCTG.

“It’s consultants and clinicians whose job it is to give that advice, and it’s for them to advise what is in the best interests of their patients before they undergo surgery.”

Vale of York CCG has been put into “special measures” legal direction by NHS England over a mounting financial crisis predicted to leave it with a £24 million deficit in 2016-17.

It was ordered by NHS England to review the same proposals three months ago to ensure they were “proportionate and clinically reasonable” but it has now been agreed they can be implemented.

Under the measures, patients with a body mass index (BMI) of 30 or above will have to shed 10 per cent of their weight before surgery or wait 12 months for operations. Smokers will have to quit for at least two months or face a six-month wait for surgery.

Three other CCGs in North Yorkshire, which also face problems amid a growing NHS financial crisis in the county, have imposed restrictions on obese people and smokers accessing surgery in recent months although they are not as tough.

Mark Dayan, Policy and Public Affairs Analyst at the Nuffield Trust, says it is not entirely clear what the new measures will actually mean in practice. “It seems like they are more like guidelines than hard and fast rules, though they feel like they’re more towards the cruder end.”

But he points out there are benefits to people losing weight before they have an operation. “There is evidence that in certain circumstances and with certain procedures that obese people have worse outcomes,” he says.

The new measures are something of a test case – one that stems from financial pragmatism. Nevertheless, there are serious concerns among patient groups about the possible ramifications.

Tam Fry, spokesman of the National Obesity Forum, argues that the move is unethical. “The whole point of the NHS is that when you need treatment you get it,” he says.

He also believes it will do more harm than good. “All it’s doing is adding to the cost ultimately of the operation and it’s also adding to the misery of those people who need the operation.”

Fry says people need support not criticism. “Life isn’t fun if you’re obese and the effort to lose weight can often be difficult and debilitating. If you’re a pensioner you’re more inclined to put on weight. Being fat is not about sheer gluttony, there are often genetic or metabolic reasons why someone is overweight.”

At the heart of all this, of course, is concern over the huge financial black hole facing the NHS. When front-line health services revealed a deficit of £460m for the first three months of the financial year, hospital trusts said it was time for a national debate about what the NHS could now afford to do if it were to remain free.

“We need a debate to happen because in the end we’re probably going to have to re-write the NHS constitution, people will have to take their turn or pay for it,” says Fry.

Nigel Ayre of patient watchdog Healthwatch North Yorkshire says the measures being proposed need to be properly scrutinised. “We have raised our concerns to other CCGs specifically about the impact on vulnerable groups such as disabled people and those with mental health problems, who statistics show are far more likely to smoke.

“These proposals could potentially have a negative impact on health inequality with people with high BMIs and smokers potentially being those on lower incomes.

“We’ve had positive talks with all CCG leads and have been told this will be more clinically led and won’t simply be used as a blunt tool. This will allow greater consideration of the impact on vulnerable groups on a case by case basis.”

He says there are clinical reasons for looking at smoking cessation and reducing patients’ BMI. “There is evidence that there are better outcomes if someone has stopped smoking or lost weight, so there are clinical benefits. But the same measures are not always as straightforward in other areas such as alcohol.”

There is a wider concern now that while there is consistency in North Yorkshire this is isn’t reflected in the rest of Yorkshire, or indeed the country, where different rules and guidelines apply.

Ayre says increasingly CCGs rather than making difficult decisions over who gets operated on and when, will need greater focus on preventative measures.

“There needs to be much greater emphasis on preventing people becoming acutely unwell in the first place. We know that early intervention makes a huge difference and more needs to be done to help people stay fit for longer. That’s the really important thing.”

A system that is under pressure

GP Shaun O’Connell, a clinical lead at Vale of York CCG, said: “The local system is under severe pressure. Supporting our population to take a proactive approach to maintaining an optimal weight through healthy eating and stopping smoking will improve their quality of life and help to ensure that we get the very best value from the NHS.

“Exceeding resources is not sustainable in the NHS and risks the ability of services being there when people really need them.

“The NHS spends around £9bn a year on patient care for those living with diabetes and with spending on obesity related ill-health and smoking related illness increasing year on year, these measures will help protect the future finances of the local health economy.”