It was recently reported that Vale of York clinical commissioning group (CCG) plans to delay all elective surgery for obese patients for a year until they lose 10% of their weight, and to smokers for six months unless they stop smoking for eight weeks. [1] Both the overall rationale for this policy and the clinical rationale for targeting these particular groups are unclear.

The most obvious objection to the proposed policy is that it is unfair to target specific patient groups in this way. Why should the obese and smokers be singled out? The rationale cannot be clinical risk: while surgery is riskier for morbidly obese patients, and smoking is bad for your health in the long term, mildly obese patients and smokers are just as likely to recover well from surgery as slim non-smokers. The CCG seems to think that it is logical to target both smokers and obese patients simply because patients who are very obese and smoke are at greater clinical risk.

The effective ban on hip and knee replacements (for example) means those most in need will go without while patients who are healthier get priority. Fatter patients not only might be in more need of a new hip; obesity increases risk of other health problems and denying them the care they need just adds to this burden. Furthermore, many obese people have been trying to lose weight for years and many smokers remain addicted to nicotine despite trying to quit; the CCG assumes that all patients in both groups have simply not tried to get healthier.

The policy also treats patients within each group unjustly. BMI is notoriously unreliable for assessing individuals rather than populations; a heavily muscular person can be classed as obese despite being perfectly healthy. There is even less rationale for denying these healthy “obese” people surgery. And even if it were fair to single out these patient groups, the criteria by which they will later be deemed suitable for treatment are illogical. Why make obese patients wait one year? During that time the symptom that needs surgery will become worse and the patient will suffer as a result. Furthermore, patients might become more obese because they are denied access to the surgery that they need to become mobile again (such as a hip replacement). Smokers who fail to quit will also be less healthy when receiving the surgery because they have smoked more. The alternative to waiting is for a patient to try to quit smoking or to lose 10% of his weight. This is also unfair as it means that someone with a BMI of 31 would have to achieve a BMI well below the cut-off of 30. It also unfairly penalises very obese patients who will have to lose several stone more than less obese patients.

It is true that denying surgery may encourage behaviour change and benefit public health, but that cannot be used as a justification for denying surgery to those who are in clinical need. In this case the motivation appears to be neither public health nor clinical need, but financial pressure. It has correctly been pointed out that a blanket ban on surgery like the one proposed would be contrary to the NHS constitution, principle 2 of which states that “Access to NHS services is based on clinical need, not an individual’s ability to pay.” It should also not be based on a CCG’s ability to pay. Following payment of incentives to CCGs for non-referral, this extreme attempt at rationing is another attempt to deny patients the services that they need. [2] Indeed, this policy will conveniently allow doctors to receive incentives for no referral for surgery. NHS bosses swiftly moved to prevent this rationing policy being put into place, but it is a sign of what the NHS could become in the future: a health service where only the “deserving” receive treatment. [3]

David Shaw is the senior research fellow, Institute for Biomedical Ethics, University of Basel, Switzerland.

References: 

1] Bodkin H. Obese patients and smokers banned from routine surgery in “most severe ever” rationing in the NHS. The Telegraph, 2nd September 2016.

2] Shaw D. Should GPs be paid to reduce unnecessary referrals? No. BMJ 2015;351:h6148

3] Press Association. Plans to deny surgery to obese patients and smokers put on hold. Guardian, 3rd September 2016.