No surgery for smokers or the obese: Policy in UK stirs debate

Two issues are the cause of a plethora of diseases and health conditions affecting people worldwide: smoking and obesity.

And one local health committee in the UK has announced a controversial policy “to support patients whose health is at risk from smoking or being very overweight.”

For an indefinite amount of time, it plans to ban access to routine, or non-urgent, surgery under the National Health Service until patients “improve their health,” the policy states, claiming that “exceptional clinical circumstances (will) be taken into account on a case-by-case basis.”

The decision comes from the clinical commissioning group (known as a CCG) for the county of Hertfordshire, which has population of more than 1.1. million.

The time frame for improving health is set at nine months for the obese in particular; those with a body mass index over 40 must reduce the number by 15% over that time period, and those with a BMI over 30 are given a target of 10%.

The target for smokers is eight weeks or more without a cigarette – with a breath test to prove it.

The new and most controversial part of the policy is that the surgery ban is indefinite, according to the Royal College of Surgeons in the UK, which opposes the policy. Other groups in the UK have implemented similar policies, but patients eventually get surgery if they are unable to lose weight or stop smoking, they said.

“The guidance for (general practitioners) and providers has been in place since 2011 for hip and knee operations and was extended in 2012 to all non-urgent routine referrals,” the East and North Hertfordshire CCG said.

Smokers had previously been advised to stop smoking and obese patients advised to lose weight, with both sets of patients informed about services available to them.

CCGs are National Health Service bodies that plan health care services for their areas, and the groups for Hertfordshire argue that improving health before surgery improves outcomes and reduces the amount of time spent in the hospital during recovery, helping the patient – and the health service budget.

Though the group says financial savings are not expected, “the wider health system may benefit from shorter hospital stays,” the CCG said.

‘Best interests of the whole patient population’

“The consultation proposals were developed by local (general practitioners) and public health doctors, with the best interests of the whole patient population of our area in mind,” said Dr. Hari Pathmanathan, a Hertfordshire practitioner and chairman of the East and North Hertfordshire CCG.

Data from public consultations and surveys reported by the CCG showed 85% agreement from the public on the need for those with higher BMIs to reduce weight and for smokers to stop, and 73% agreeing with asking people with BMIs over 30 to lose weight.

“We understand that some of our patients will have to make changes and they will be supported to do so, for example with the free weight-loss and stop-smoking advice sessions already on offer,” Pathmanathan said in a statement.

Government figures estimate that 63% of adults in the county are overweight or obese, and 15% are smokers. In the UK as a whole, 27% of the population was obese in 2015, and a similar percentage of adults to those in Hertfordshire, 15.8%, were smokers in 2016.

The new policies came under immediate attack from experts and interest groups.

“Singling out patients in this way goes against the principles of the NHS,” said Ian Eardley, senior vice president at the Royal College of Surgeons in the UK. “This goes against clinical guidance and leaves patients waiting long periods of time in pain and discomfort. It can even lead to worse outcomes following surgery in some cases.”

The conversation has been going for some time, experts agree, but the question is the ethics – and whether it would even work.

“Rationing treatment on the basis of unhealthy behaviors betrays an extraordinary naivety about what drives those behaviors,” Robert West, professor of health psychology at the UCL Research Department of Epidemiology and Public Health, wrote in an email.

‘Tip of the iceberg’

A 2016 report by the Royal College of Surgeons found that more than one in three CCGs in England are denying or delaying routine surgery to smokers and obese patients in some way, with the college warning that such patients were becoming “soft targets for NHS savings.”

The Hertfordshire decision has taken this to a new level by making the ban indefinite.

“We are concerned that the policies in Hertfordshire are just the tip of the iceberg,” Eardley said.

The same report found that about 20% of these groups place mandatory weight thresholds on referrals for knee and hip replacement surgeries, an increase from 13% just two years earlier, in 2014.

“We know that these policies have become much more commonplace since” the 2016 report, Eardley said. “What is especially concerning is that not only are more clinical commissioning groups implementing such policies, they are also implementing increasingly harsher policies, restricting patient access to surgery even further.”

These harsher policies include requiring patients to be in varying degrees of pain or imposing bans on surgery for several months to save money, he said.

Questionable cost-efficiency

The committee papers outlining the changes state they encourage patients to take more responsibility for their own health and well-being, enabling greater resources for priority treatments.

In the case of surgery, reducing obesity and smoking in patients can reduce the risk of serious complications during and after surgery, shorten hospital stays and help patients recover better, the CCG argues, reducing expenditure.

But other experts do not agree.

“Often, we find that these policies are brought in to help alleviate financial pressure. The irony is that such policies can actually cost more as patients are simply treated at a later date and may need other health care in the interim,” Eardley said.

Martin McKee, professor of European public health at the London School of Hygiene and Tropical Medicine, believes the only reason to withhold treatment or surgery is if it would not work, somehow be detrimental to the patient, or if the cost far outweighed any benefit, “which is not the case here,” he said.

“The NHS is a service that is meant to be free at the point of delivery and every person should be judged as an individual,” he said.

Questions of evidence and ethics

McKee’s first reaction to the policy was to ask for evidence to back up banning surgery for this subset of patients.

In response, the East and North Hertfordshire CCG provided National Health Service reports highlighting the need for doctors to optimize the health of their patients for the best results from enhanced recovery after surgery and showing that medical triggers have been shown to promote long-term behavior change, such as changes to diet, exercise and smoking.

McKee agreed that wounds heal faster and recovery is quicker in nonsmokers and that services should be provided and promoted to patients to help them.

But the evidence he wants is different: showing that withholding surgery works to reduce obesity and smoking. The CCG did not specifically address whether this evidence exists and a representative said it won’t answer any more questions about the surgery ban.

McKee also questions the accountability of CCGs, as they are not a publicly elected body.

Then “we can go on and discuss the morality of it,” he said.

West agreed. “Economic, health and moral arguments point to ensuring that patients have provided with ready access to evidence-based support for tackling their problem behaviors,” he said, “rather than seeking to impose counterproductive, unethical and unworkable restrictions on their health care.”