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You can find the current article at its original source at http://www.theguardian.com/commentisfree/2016/apr/25/delaying-surgery-obese-patients-smokers-nhs-cut

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Is delaying surgery for obese patients or smokers a covert NHS cut? Is delaying surgery for obese patients or smokers a covert NHS cut?
(4 months later)
Mary is 55, smokes 20 a day, has a BMI of 33 and now has abdominal pains. An ultrasound scan shows gallstones. She’s referred to the surgeons to have her gallbladder removed. She waits four months for an appointment and is bitterly disappointed when told she should stop smoking, lose weight and then be re-referred by her GP if the pains continue. Mary thinks she’s being discriminated against and wants to complain. Is she right?Mary is 55, smokes 20 a day, has a BMI of 33 and now has abdominal pains. An ultrasound scan shows gallstones. She’s referred to the surgeons to have her gallbladder removed. She waits four months for an appointment and is bitterly disappointed when told she should stop smoking, lose weight and then be re-referred by her GP if the pains continue. Mary thinks she’s being discriminated against and wants to complain. Is she right?
The Royal College of Surgeons (RCS) is concerned that local GP-run clinical commissioning groups (CCGs) may be trying to balance their books by restricting access to hospital-based services such as surgery.The Royal College of Surgeons (RCS) is concerned that local GP-run clinical commissioning groups (CCGs) may be trying to balance their books by restricting access to hospital-based services such as surgery.
In a report published on Friday, the RCS said that one in three CCGs “deny or delay routine surgery to patients – such as hip and knee replacements – until they stop smoking or lose weight, in contravention of national clinical guidance”.In a report published on Friday, the RCS said that one in three CCGs “deny or delay routine surgery to patients – such as hip and knee replacements – until they stop smoking or lose weight, in contravention of national clinical guidance”.
At first sight, this seems ethically wrong and legally discriminatory. There may be an agenda of cost-cutting by CCGs, but does that mean there is no justification for delaying the referral of people such as Mary for non-urgent surgery?At first sight, this seems ethically wrong and legally discriminatory. There may be an agenda of cost-cutting by CCGs, but does that mean there is no justification for delaying the referral of people such as Mary for non-urgent surgery?
Why would you want to sign up for surgery before giving lifestyle changes a go?Why would you want to sign up for surgery before giving lifestyle changes a go?
The key principle that guides doctors is derived from Hippocrates and says “first, do no harm”. Mary’s pain might be due to her gallstones or acid reflux. Weight loss and a low-fat diet are likely to help her symptoms. If she has an operation – even “keyhole” surgery – she will be at greater risk from the anaesthetic and post-operative complications, such as blood clots, while she smokes and is overweight.The key principle that guides doctors is derived from Hippocrates and says “first, do no harm”. Mary’s pain might be due to her gallstones or acid reflux. Weight loss and a low-fat diet are likely to help her symptoms. If she has an operation – even “keyhole” surgery – she will be at greater risk from the anaesthetic and post-operative complications, such as blood clots, while she smokes and is overweight.
A Swedish study of 3,309 people who had a hip replacement showed that the risk of post-operative complications was increased by 121% in heavy smokers and 58% in obese people. “Greater efforts should be taken to reduce the impact of preventable lifestyle factors, such as smoking and high body-mass index, on the post-operative course of total hip replacement,” said the authors.A Swedish study of 3,309 people who had a hip replacement showed that the risk of post-operative complications was increased by 121% in heavy smokers and 58% in obese people. “Greater efforts should be taken to reduce the impact of preventable lifestyle factors, such as smoking and high body-mass index, on the post-operative course of total hip replacement,” said the authors.
Doctors have no trouble in applying this principle to medication. If your cholesterol or blood glucose are a bit raised but you are in no immediate danger, you will surely want a chance to lose weight, change your diet and exercise a bit more before embarking on medication that can cause side-effects. Why would you want to sign up for surgery before giving lifestyle changes a go?Doctors have no trouble in applying this principle to medication. If your cholesterol or blood glucose are a bit raised but you are in no immediate danger, you will surely want a chance to lose weight, change your diet and exercise a bit more before embarking on medication that can cause side-effects. Why would you want to sign up for surgery before giving lifestyle changes a go?
Related: Smokers and obese people 'soft targets' for NHS savings, say surgeons
Similarly, take 78-year-old Vince. He lives on his own, has a painful left knee and wants a referral to have a knee replacement. Local guidelines say he has to have physio, can be considered for a painkilling injection if he meets certain criteria, and only then can he be referred. This is not necessarily a bad thing; the operation is a daunting prospect for Vince, the physio will improve his overall fitness and may help the knee pain, and the operation will fix his knee but won’t cure his other joint problems and lower back pain.Similarly, take 78-year-old Vince. He lives on his own, has a painful left knee and wants a referral to have a knee replacement. Local guidelines say he has to have physio, can be considered for a painkilling injection if he meets certain criteria, and only then can he be referred. This is not necessarily a bad thing; the operation is a daunting prospect for Vince, the physio will improve his overall fitness and may help the knee pain, and the operation will fix his knee but won’t cure his other joint problems and lower back pain.
Surgeons and orthopaedic surgeons don’t necessarily see things the same way; they tend to see severe cases that require surgery, not people who have avoided surgical intervention by changing their lifestyle or finding alternatives.Surgeons and orthopaedic surgeons don’t necessarily see things the same way; they tend to see severe cases that require surgery, not people who have avoided surgical intervention by changing their lifestyle or finding alternatives.
Politicians are failing to fund the NHS adequately. CCGs have been given responsibility for running local health services on a budget that cannot possibly match demand. GP-run CCGs are the government’s scapegoats; as cuts bite deeper, and people squeal louder, GPs will rue the day they agreed to accept this poisoned chalice. Blanket bans on individuals accessing services is indefensible.Politicians are failing to fund the NHS adequately. CCGs have been given responsibility for running local health services on a budget that cannot possibly match demand. GP-run CCGs are the government’s scapegoats; as cuts bite deeper, and people squeal louder, GPs will rue the day they agreed to accept this poisoned chalice. Blanket bans on individuals accessing services is indefensible.
But – and it’s a big but – that is not the same as saying that everyone should be treated the same when it comes to non-urgent surgery. If you need an op but it’s not urgent, why not do everything possible to minimise your risk of dying on the operating table, or soon after? And if that means delaying your op while you try to lose weight or stop smoking, surely that’s in your best interests?But – and it’s a big but – that is not the same as saying that everyone should be treated the same when it comes to non-urgent surgery. If you need an op but it’s not urgent, why not do everything possible to minimise your risk of dying on the operating table, or soon after? And if that means delaying your op while you try to lose weight or stop smoking, surely that’s in your best interests?