Should overweight people and patients who smoke, be barred from surgery on the NHS?
Is refusing care justified on medical grounds or is this simply a cost cutting exercise? Morland Sanders meets the patients in pain, angry at being denied treatment because of their lifestyles.
Viewers may have seen various press reports this morning that suggested individual Primary Care Trusts (PCT’S) were refusing NHS treatments because of patients lifestyle choices; namely smoking and obesity. The following PCT’s have asked us to clarify their positions which we are happy to do.
West Essex NHS Trust
We recommend that patients who smoke quit for at least eight weeks before their procedure. The PCT stop smoking service can support them to achieve this. We recommend that patients with a BMI over 30 lose weight before their procedure. The PCT support patients to do this through health trainers and PCT healthy lifestyle programmes. We have this criteria in place to make sure that all patients have the best chance of recovering and getting well more quickly. Clinical evidence shows that patients who smoke or are obese are more likely to take longer to recover and suffer from heart and lung problems following surgery. However we do not currently delay the majority of procedures if the patient is unwilling to follow this health advice and criteria. We only currently apply the criteria to specialist restricted services such as plastic surgery, but provided the patient accepts PCT support we will undertake the procedure as soon as is appropriate. The criteria does not apply to emergency procedures. We do not have any patients experiencing a delay for their non emergency operations or procedures as a result of this criteria.
North Staffordshire PTC
Obesity Surgery - Should not consider referral unless BMI is over 40kg/m2 and lifestyle and pharmacological interventions have been undertaken and failed. Hip & Knee Replacement Surgery for Arthritis - Consider referral only if:
The patient has a BMI below 30 and conservative means (e.g. analgesics, physiotherapy) have failed to alleviate the patient's pain and disability. If BMI above 30 then consider referral for a lifestyle support programme initially
In the rare cases of severe uncontrollable pain with rheumatoid arthritis, consider urgent referral.
Carotid Endarterectomy
Should not receive an operation if asymptomatic or mild to moderate carotid stenosis.
Smokers should be referred for a sustained smoking cessation programme prior to referral for surgery.
Halton and St Helens PCT
Halton and St Helens PCT does not have any blanket policies on restricting access to treatment for patients due to their body mass index. It does not have any blanket policies on restricting access to treatment for patients due the fact that a patient may smoke. The trust does not have any blanket policies restricting access to treatment due to financial implications. Decisions as to whether or not to proceed with a surgical intervention are subject to consultations between the patient and their treating consultant or surgeon. Decisions to treat are made by considering the risks and benefits and also the likelihood of the proposed intervention achieving the desired outcome. Primary Care Trusts commission surgical services based on their assessment of the needs of their local population and available service capacity. The provision and availability of a particular surgical intervention should be dependent on the clinical need of the individual patient. Halton and St Helens PCT is committed to ensuring that patients have access to treatment that is free at the point of care and based on clinical need. Very clear guidance to the National Health Service has been issued, stating that clinical need must be the main determinant when prioritising patients. An independent body, NICE, decides whether drugs and treatments are clinically right and cost-effective for the NHS, based on the latest evidence.
Herefordshire PCT
The main factor which Herefordshire PCT takes into account in what treatments it funds is the clinical needs of the patients. We do not refuse or restrict funding for treatments for patients who smoke. We recommend that people referred for IVF treatment who smoke are also referred for “stop smoking” advice, but IVF treatment is not restricted if they choose not to take this up. We will not normally fund non urgent hip and knee replacements for patients with a BMI over 40, because the clinical evidence is that these particular operations are not effective for patients of this weight. However, this is not a blanket criteria, and we will consider individual cases of people with BMI over 40 based on their particular clinical need and circumstances. There are no other criteria for non emergency operations or procedures based on BMI which we use.
Stoke on Trent PCT
Supporting patients to lose weight, quit smoking and improve their overall health is preferable to surgery and where surgery is required, helps to ensure better outcomes and a speedier recovery. (Many joint problems are caused by excess weight, and losing weight can be an effective alternative to surgery.) Under a policy approved by clinicians, patients with a BMI of over 30 or who smoke are offered a referral to a Lifestyle Support program that the PCT funds. They can then choose from a menu of services to help them to lose weight, quit smoking and to exercise. Emergencies are unaffected by these referral criteria, and clinicians have the option to refer patients without offering the Lifestyle Programme if they judge this to be clinically necessary. Clinicians also review patients who are on the programme every 3 months and if the patient’s condition is getting worse have the option to refer them straight to surgery irrespective of their BMI or smoking status.”
County Durham Primary Care Trust
County Durham PCT does not have an overarching policy which precludes surgical treatment because of lifestyle choices. All treatments are based on clinical decision making by the clinicians involved with the patients. In some cases clinicians will not recommend surgery when a patient is obese because of the risk of complications. This is a clinical decision. The PCT does restrict access to certain aesthetic surgery procedures (eg apronectomy) until the patient has reached the required weight loss. This is in keeping with agreed good practice.
Bedfordshire PCT
Dr Jane Halpin, Director of Public Health for the two Hertfordshire PCTs and Dr Dorothy Gregson, Director of Public Health for Bedfordshire PCT said: "The primary care trusts in Hertfordshire and Bedfordshire do not have policies in place that refuse procedures to smokers and obese patients. We do have draft referral guidelines which recommend that GPs advise overweight or obese patients on how to lose weight and motivate smokers to quit before referring them to routine joint replacement surgery (knee or hip). The main reason for this is to reduce the risks of anaesthetic or operative complications. It is not the case that if patients are unable or unwilling to lose weight or to quit smoking that we deny or delay their operations. The final decision as to whether it is clinically safe to operate on patients who smoke or who are overweight is taken by the surgeon performing the procedure. PCTs' public health and clinical teams work with partner organisations to support people who want to lead healthier lifestyles. Initiatives include stop-smoking services, healthy schools activities and programmes of healthy walks for people of all abilities.”
Norrfolk Primary Care Trust
Norfolk Primary Care Trust does not have a policy in place which imposes restrictions on surgery for people who are overweight. Dr John Battersby, Director of Public Health for Norfolk Primary Care Trust explains: “We have no such policy and it is totally inaccurate to say we do. I would like to reassure the local people of Norfolk, that we would not prevent anyone having surgery for that reason and strongly refute this suggestion.”
LINCOLNSHIRE PCT
As long as they (patients) can demonstrate they have tried to stop smoking or lose weight doctors will consider every patients individual circumstances. Patients who smoke and/or are overweight have a significantly high risk of complications following operations. The PCT does not ban people from having an operation. An independent appeals process is in place. The final decision rests with the clinician treating the patient.
MILTON KEYNES PCT
“We do not have any criteria in place that could, on the basis of a patient’s BMI or smoking habits, delay their surgery once the patient has been assessed by a consultant surgeon as needing surgery. We have, however, asked GPs to assess their patients prior to referral and strongly advised them to support their obese patients to lose weight and patients who smoke to stop before any referral to surgery is made.”
SUFFOLK PCT
Dr Padmanabhan Badrinath, Consultant in Public Health Medicine, said: “We have in place guidelines to encourage people to lose weight in order to improve their recovery rates following surgery. People with a body mass index of more than 35 are given support and advice on how to lose weight, or referred to slimming classes if that is appropriate for them, prior to surgery. Losing weight is not only good for them and their health, but there is also evidence to show that people with a BMI of under 35 will have fewer complications following surgery and their recovery rates are better.
After three months of attempting to lose weight, patients are put on to the waiting list for surgery regardless of the results in terms of weight loss. There is a small minority of patients in whom attempting to lose weight may do more harm than good and these patients are considered on a case by case basis and a decision is arrived at in consultation with their treating consultant. We also refer all smokers identified as needing routine elective surgery to smoking cessation services prior to their operation. Smoking cessation will take place whilst the patient is awaiting surgery. Patients neither have surgery denied nor delayed due to the fact that they are smokers. Instead, they are offered an opportunity to improve their health six to eight weeks before undergoing a surgical procedure.There is considerable evidence to show that non-smokers recover more quickly following surgery. They are also less likely to have complications from the anaesthetic and they spend less time in the recovery room. "
Suffolk Primary Care Trust
Dr Padmanabhan Badrinath, Consultant in Public Health Medicine, said: "We have in place guidelines to encourage people to lose weight in order to improve their recovery rates following surgery.People with a body mass index of more than 35 are given support and advice on how to lose weight, or referred to slimming classes if that is appropriate for them, prior to surgery. Losing weight is not only good for them and their health, but there is also evidence to show that people with a BMI of under 35 will have fewer complications following surgery and their recovery rates are better. After three months of attempting to lose weight, patients are put on to the waiting list for surgery regardless of the results in terms of weight loss. There is a small minority of patients in whom attempting to lose weight may do more harm than good and these patients are considered on a case by case basis and a decision is arrived at in consultation with their treating consultant. We also refer all smokers identified as needing routine elective surgery to smoking cessation services prior to their operation. Smoking cessation will take place whilst the patient is awaiting surgery. Patients neither have surgery denied nor delayed due to the fact that they are smokers. Instead, they are offered an opportunity to improve their health six to eight weeks before undergoing a surgical procedure.There is considerable evidence to show that non-smokers recover more quickly following surgery. They are also less likely to have complications from the anaesthetic and they spend less time in the recovery room. In smokers, wound healing is slower due to harmful substances in cigarette smoke. The benefits of smoking cessation go beyond the operation. If individuals continue to stay off cigarettes it will have a massive impact on their long term health, wellbeing and quality of life.We would like to reiterate that there is no question of stopping people from having their operations or delaying them due to their smoking status.
