Here's a good one for debate. A local NHS organisation in North Yorkshire has banned surgery for obese people (BMI over 30) for a year, in an attempt to save money and to 'encourage' them to lose weight - 10% to get back on the list. This excludes life saving surgery. A fat doctor (a doctor who treats fat people, rather than a doctor who is fat. Though it was on the wireless so he may be a fat fat doctor) likened this policy to racism. Also banning elective surgery on smokers for 6 months unless they quit. Some operations are less effective if you are fat, or the condition will return if you don't lose weight (some orthopaedic stuff, some heart/vascular stuff), so there are medical reasons to deny the porky treatment. Others, like cataracts, have nothing to do with weight. The smokers argument is an interesting one as well. Smoking is legal and the government raises more revenue from it than what treating smoking related diseases costs. So the obese and smokers are targeted to help save money to treat the rest of the population, presumably including drug users and alcoholics. There are 14.5 million people classified as obese, and 61% of the adult population are obese or overweight, it might be a very effective way of saving money if applied nationally. There are 9.6 million smokers. Opinions awaited with interest.
I agree it's inadvisable to spread "expertise" too thinly. Where surgery is needed, I would have thought it possible to transfer patients from a non-surgical hospital to a specialist surgical hospital where senior consultants work a 7 day week, and then take the patient back for convalescence. Patients coming into A&E are offered transfers to another hospital (my mother was, and regrettably didn't take it up), so I don't see why using a "hub" hospital for expert treatment is out of the question.
I agree with the principal of what is being done, but harsh effects must be mitigated. Dealing with obesity, it makes no sense to give a 24 stone man a new knee, if the knee will cease to operate within a year or two due to downward pressure. So, yes, he must lose weight first, and since over-eating can sometimes be caused by deep seated psychological issues, NHS assistance should be offered to the patient to assist in this process. Smokers, drug addicts and alcoholics could be treated similarly, if the addiction is going to negate the NHS treatment being undertaken. Of course, there's nothing to stop the patient taking up bad habits after an operation. George Best is a classic example, taking a new liver and then falling off the wagon with fatal effect.
The short answer is that the public and professional outcry when they think their local hospital is being reduced in some way is such that you end up paralysed, in judicial reviews etc for years and years. I was involved in stuff in a particular part of the country where one hospital was delivering so few babies that it lost its accreditation for maternity services - it wasn't safe they had so little practice of complicated births - that set off a domino effect, the hospital could no longer have A&E without maternity which rippled into surrounding hospitals. This was 1996. The ripples are still being worked through. I had to save paperwork long after I left the firm which did the consultancy, in case I was subpoenaed. On paper, it's easy and logical. I used to run processes with large groups of doctors, managers, politicians, patients representatives, get them to redesign services in a 'safe' environment (i.e without the real geography). Must have done this a dozen times, back in the late nineties, all over the country. The result was universally exactly as you describe - fewer bigger hospitals with everything in them, more community hospitals for routine treatment, some diagnostics and rehabilitation close to home - everybody agreed. Until we reinserted the real geography on the model and asked which of the existing hospitals are going to downsize or close. Cue chaos, often led by doctors as they realised they might have to travel further to work or be more flexible. This is why I fear that, even though the NHS may be underfunded, it's root problems lie much deeper, in service design and workforce planning. To be fair there has been some shift towards your model, but it is patchy and communicated and explained extremely poorly. I still have a least 6 hospital within 60 minutes drive (in good traffic) of me with an A&E, much less in an ambulance with the blue light and siren on. Several of them I would attempt to direct the ambulance away from. The well informed always do better in these circumstances. My Mum had a major, non lifestyle incurred, heart problem a couple of years ago, and needed huge surgery (heart lung machine etc). Oxford was the logical place for her to go, given that she lives in the east Cotswolds, but when I looked into it I ended up getting her referred to Bristol, because the team was better there. Necessitated a lot of driving and inconvenience, but the op was a complete success, albeit brutal for a 75 year old. Only a minority of us know how to get the info and are prepared to push for what we want.
What about the cataracts example? Do you think it would be appropriate for those who are refused treatment to withhold a portion of their taxes for services they are not getting access to? Personally I think that all decisions should be left to the clinicians. If they feel someone won't benefit from an op because they are too fat, fine.
That's a really well-informed reply, Stan. And what you describe is close to the experience with my mum. She was taken down to St Richard's Hospital, Chichester (historically known by locals as Dirty Dicks"). It has gone through some improvements recently, but elements of it were like a third world hospital. After the shockingly poor op, my mum was transferred to Royal Surrey in Guildford which is where you want to be if you are ill. The surgeon there was fantastic. Chalk and cheese. The NHS needs reform badly to lift the failing hospitals.
Yes, if obesity has no medical relevance to cataract treatment, then the treatment should be given irrespective of a patient's weight. I don't think taxes have anything to do with it. As you say, if a clinician advises that treatment for someone with weight problems or addictions is not cost effective until the patient's underlying problem is resolved, than that should be conclusive.
I would prefer 'clinically effective' to 'cost effective', but I think we agree. Little story from my Mum's case. I used to go with her to her appointments with consultants. There were crowded waiting rooms, but I noticed that her consultations were quite long and we spent a lot of time just chatting. I asked the surgeons about it. The response was that my Mum's condition was completely out her her control, just bad luck, and that she is an articulate and pleasant lady, and that I was clearly well informed, which meant the chats were stimulating. They regarded it as a perk to chat with people like us, compared to many in the waiting room who had self inflicted heart problems, would have expensive and time consuming surgery and would make no attempt to lose weight and whine about how to get outside to smoke while still recovering from operations. They would all be back or dead in short order. Elitist, arrogant and soul destroying.
Increasingly, with the financial pressures the NHS is under, I think both descriptions will be relevant. Priorities will have to be made between patients, so that funds are used most efficaciously. I think we are starting to see this happen.
They already are. The drugs my company makes are subject to cost effectiveness assessment before they are made available in the NHS, through NICE. Which means, due to the complexities of international price referencing for medicines, many new drugs are either never available in the UK or available much later than in other European countries, and much much later than in the US and Japan. And yes, we do have the lowest European prices for the UK. One possible consequence of Brexit (not that I want to get into that again) is that we will delay launching stuff in the UK until everywhere else is done and we can be more flexible on price. Can't do this at the moment as the UK is part of the EU medicines regulatory system. I should stress that the NICE system is fair and transparent, just very challenging for manufacturers who work internationally. And patients are already prioritised according to maximum benefit, even if this may not be explicit. The main 'rationing' tool though is waiting lists, which are also the least logical and least efficient.
Taking the cataract example, there's such a minefield. Eating and smoking are legal so why should illegal drug users not have similar delays. Is obesity or smoking significantly worse than drinking and aren't relative levies on these already meant to level this out (speaking naively) so why the need for additional penalties? Then there's the point where anybody but the obese has a realistic chance of lying about their habbits so isn't it then judging people on appearance unless you're going to do tests to identify issues. At which point, why not do a full medical? Personally, I still smoke (albeit more erratically these days) but I'm two weeks away from running a half marathon, only weigh about 10 stone, only drink about 25 units of alcohol a month and probably have lower cholesterol than many who would receive quicker care. It's picking out the same obvious targets who are already taxed extra (luxury food Vat as flawed as that is, sugar tax, duties etc) to save money. Arbitrary and unfair at best.
The people making these decisions understand all of your well put points Matt. They know it is unfair, divisive and fraught with problems. I am 100% certain they don't want to do it, but are desperate for new ways to save money and keep the service afloat. What is interesting is that they are making these decisions at local level without any guidance, direction or policy from central government, which I am sure is in denial about the state of the NHS. And of course this reintroduces postcode prescribing, a *** puffing porker a couple of miles down the road will not be subject to the same restrictions.
If you are going to stop treating obese people and smokers, why not go the whole hog. Here are some examples where more money can be saved; Drinkers - anybody who drinks more than 10 drinks a week should have all medical treatment refused. Drug users - stop all treatment asap. Mental health issues - as they brought it upon themselves - just lock them in their own homes . Pregnant women - if a woman wants more than 2 kids, let her deliver them herself. Car crash victims who don't wear seat belts. Don't even send an ambulance. Just leave em on the road. Note - all the above are tongue in cheek comments and none are my own serious opinions.
I suppose it highlights the cracks already there - local bugets are strained and the government only gives spending targets so aren't in a position to say how it's spent without a significant public outcry. It also means that the government don't have to answer questions about how duties and luxury food taxes are distributed and nobody can rightly expect local authorities to do so either. It's more like a monarchy - ruling without answerability (just invented a word) from the safety of a castle.
It isn't about punishing patients for past misdemeanours or idionsyncracies. It's about helping put a patient into the best physical condition pre-operation, so that the treatment has the most likely chance of success.
I read it as all non-emergency procedures and not just delaying ops for obese people where the op relates directly to weight say. Finglas' tongue in cheek comment is that far removed from reality.
It's obese-specific at the moment. It gives the patient a chance to prepare for the op, and for the NHS to, putting it bluntly, get full value for money when the op is carried out. I'm afraid Finglas is away with the fairies with his light-hearted examples!
That's the way I read it too, regarding the operations. I also read it as a desperate cry for help from local NHS organisations - the debate this will spark and the pressure it will put on Useless CHunt is exactly what they want. It's a nightmare scenario but if it encourages some people to look after themselves better not all bad.
That is the closest you have ever come to giving me a compliment so thanks a lot. Listen, I am not that interested in British domestic politics. My comments were just light hearted. Enjoy your discussion.
If you'd come out for Brexit, I'd have showered you with compliments! I took your comment to be what they were, a bit of mischievous fun with a hint of a left-wing tilt. Hope that's fair. I just know one of these days we're going to agree on something, Fingy, but until then, I always enjoy your posts
