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Devon’s slimmed services for smokers and obese patients: encouragement or blackmail?

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Efforts to guard essential services while maintaining financial sustainability have led NEW Devon CCG to require patients with a BMI of over 35 to shed 5% of their body weight before non-essential surgery. The same applies to smokers who are required to quit 8 weeks before their operations.

It is now accepted that smoking and obesity contribute sizeably to the UK’s burden of cardiovascular disease, cancer and diabetes, but is taking action at the “supply end” of service provision an ethically sound or equitable way to address these issues?
NEW Devon CCG argues that surgery on the obese is more difficult to perform and its results “possibly” more hazardous for an obese patient. They further suggest that by losing weight some patients might not need surgery at all.

Nevertheless, patients are referred for procedures such as hip or knee operations due to these conditions having a negative impact on their daily living. To lose weight is difficult in the best of circumstances, thus it seems strange, perhaps cruel, to expect patients with mobility issues to become more active in order to loose weight. The prospect of surgery is also stressful for many, perhaps making it even harder for smokers to suddenly abstain.

Equity issues also emerge with this proposal. Impoverished parts of UK cities are often “obesogenic environments”. Here people may work long hours in stressful shift patterns; having little time to cook nutritious meals and consequently consume more fattening fast food. The Whitehall studies have also shown us that there is a social gradient to the incidence of smoking within the population. Devon’s proposed measures would seemingly therefore have a disproportionate effect on the wellbeing of poorer groups.

Many have rightly argued that the NHS needs to shift its focus from the hospital to the community at large; promoting general public health and consequent disease prevention. To remain healthy, modern lifestyles must change and the public must cooperate with health professionals rather than simply turning to them for “emergency repair”. However, such cooperation should be achieved through education and “nudge polices” rather than by the threat of withdrawing access to surgery.

The NHS exists to “treat all members of society, regardless of ability to pay”. To deny services to some groups due to their lifestyle choices may well compromise these values. Some overweight patients might be so due to wide ranging causal factors such as childhood diet or stressful life experiences. If we are to start excluding “unhealthy” or “risky” groups from access to services, where do we draw the line? Should skiers be charged for the treatment of a broken ankle? Should a motorcyclist’s fractured ribs be treated only after an agreement to sell their motorbike?

Many lifestyle choices are lawfully and freely adopted with the knowledge of their accompanying risks. Without major dialogue regarding our understanding of the NHS’s role or of our legal responsibilities as citizens, the NHS should not arbitrarily decide whether or not to treat the sometimes unfortunate results of these lifestyle choices, even if to do so might require additional funding. We should focus on education, assistance and partnerships with patients, not threats.

Edmund Stubbs, Healthcare Researcher, Civitas


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