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Overweight and smoking patients ‘soft targets’ for withholding surgery to save money

Patients are missing out on surgery if they are overweight or smokers in one-third of CCGs, new research shows.

Research from the Royal College of Surgeons (RCS) shows that 34% of CCGs have at least one mandatory threshold based on BMI or smoking status, despite official guidance saying that surgical commissioning should be based on clinical evidence, not financial considerations, and should not be denied on the basis of factors such as weight or smoking.

For hip and knee replacements, 22% of CCGs have mandatory weight thresholds, a significant increase from 13% in 2014, and 17% encourage voluntary weight loss before surgery.

Six south west London CCGs and Swindon, Gloucestershire and North Lincolnshire CCGs require a patient to commit to lowering their BMI to below 30 before surgery, 21 CCGs require a BMI below 35, and 15 require a BMI below 40.

Funding pressures may lead to surgery being denied

Clare Marx, president of the RCS, warned that CCGs may be feeling forced to implement the policy in a bid to tackle the NHS deficit.

She said: “Public health programmes that assist healthy weight management and quitting smoking are fully supported by the College. Affected patients should be encouraged to attend these services while awaiting surgery. However blanket bans that deny or delay patients’ access to surgery are wrong. NHS surgical treatment should be based on clinical guidance and patients should be dealt with on a case by case basis. In some instances a patient might need surgery in order to help them to do exercise and lose weight.

“While it is difficult to categorically prove such policies are aimed at saving money, it is unlikely to be a coincidence that many financially challenged CCGs are restricting access to surgery. Our worry is that smokers and overweight patients are becoming soft targets for NHS savings.

“There is no clinical guidance from NICE, the Royal College of Surgeons, and other surgical associations to support mandatory bans for routine surgery on the basis of whether patients smoke or are overweight.”

The chairs of NHS Clinical Commissioners (NHSCC) disagreed with the accusation.

Dr Graham Jackson said: “CCGs are clinically led organisations that make clinically led decisions centred on the needs of their patients and local populations and to imply that their motivation is purely financial is wrong.”

Dr Amanda Doyle, his co-chair, said that asking patients to lose weight was about reducing the risk to the patient, not about money.

She added, however: “We agree there is a need for a shift in culture that means we all work together to focus on the best outcomes for patients, rather than on savings.”

Two CCGs (Luton and North East Essex) require patients to stop smoking before receiving any non-emergency surgery. Eight CCGs have a mandatory smoking policy before hip and knee surgery and six have a voluntary policy.

‘No justification’ for refusing to fund surgery

Tim Wilton, president of the British Orthopaedic Association, said: “There is no clinical, or value for money, justification for refusing to fund hip or knee replacements based on BMI or smoker status. Good outcomes can be achieved for patients regardless of whether they smoke or are obese, even at BMIs of over 50, and these surgeries are highly cost effective: typically delivering sustained pain relief for a cost that equates to just £7.50 a week.

“Hard-and-fast rules also undermine the NHS’s ability to involve patients in decisions about their own care, and are a distraction from the task at hand: making sure patients receive the best possible advice and care, to enable them to make the best possible decisions for their health – including losing weight and stopping smoking where appropriate. These comorbidity issues are best dealt with by appropriate informed consent and not by management dictat.”

Three CCGs have mandatory BMI policies before hernia surgery and two have voluntary policies. Seven CCGs have voluntary BMI policies before tonsillectomies for sleep apnea and two have mandatory policies. Six have mandatory policies and five have voluntary policies for varicose vein surgery.

Likewise, two CCGs (Cambridgeshire and Peterborough, which is in deficit following the collapse of its deal with UnitingCare, and Kernow) have a mandatory smoking policy before hernia surgery and two (Dorset and Bath and North East Somerset) for tonsillectomies. Five CCGs require patients to stop smoking before varicose vein surgery.

Katherine Murphy, chief executive of the Patients Association, said:  “Withholding surgery for these patients is unjustified. This seems like an underhand way of CCG’s improving their financial forecasts at the price of the patients.”