The recent news that obese patients may face restrictions on access to non-life threatening surgery initially screams "discrimination" - and indeed, by definition, it is. However, this type of discrimination has been in place within the NHS for decades. Indeed, triaging of patients in this way is absolutely vital, not only for the system, but also for patient health.

Elderly patients are already treated differently to younger patients when it comes to non-emergency surgery. Elderly patients, like obese patients, usually present with a number of comorbidities, and are at considerably higher risk of complications or death during or following general anaesthetic.

In obese patients, the cardiovascular system is also under heightened strain due to their body mass. Hypertension and obesity frequently coexist, as do other conditions which can affect the heart, arteries and vessels - such as diabetes

Of course, the financial motivation behind denying high-risk patients non-emergency surgery cannot be denied, and it is presumably this factor which causes the most concern. A blanket approach of restricting surgery for all people, purely on the basis of their BMI, is understandably controversial. However, as well as the greater perioperative risks and therefore greater care required for such patients, obese patients are frequently referred for preoperative heart scans by anaesthetists who are worried about how the patient's body will cope under general anaesthetic - referrals which are, in themselves, highly contentious. These extra diagnostic tests clearly put greater financial strain on the NHS. So as crude as a BMI-based treatment decision may be, certain facts are undeniable.

If the decision to bar obese patients from elective surgery is to go ahead, it will be important to pair this with a more sensible approach to diagnostic testing, if cost savings are to be fully realised. For example, it is not uncommon for patients in their 90s to be referred for diagnostic echocardiograms (usually under the current 'GP Open Access' scheme), despite the fact that - regardless of the result - very little action will be taken in such a high-risk patient (one important exception might be in the case of critical aortic stenosis, where a TAVI may be considered. However, such a condition should be obvious on auscultation, and hence the echo referral would be wholly appropriate). If other high risk groups are to face restrictions to access to non-emergency surgery, it is important to also avoid putting such patients through a battery of diagnostic tests, which will have no immediate benefit.

 

Social Media Update: A common argument across social media at present is that, by denying obese patients access to hip and joint surgeries unless they lose 10% of their body weight, you prevent them from being able to exercise and therefore hinder their ability to lose weight. This is somewhat of a moot point. At the stage at which an individual's BMI is over 30, weight loss becomes a simple matter of arithmatic (calories in vrs calories spent). By far the easiest way to achieve weight loss at this level is by a change in diet composition.

A counter-argument could quite easily be that, if a patient is really suffering from their current joint pain, the incentive to lose 10% of their weight should be relatively high.  

 

References

BBC News (2016), Obese patients face NHS surgery ban to save money. Online: http://www.bbc.co.uk/news/uk-england-york-north-yorkshire-37265752

Koh, A., Flores, J., Keng, F., et al. (2012). Correlation between clinical outcomes and appropriateness grading for referral to myocardial perfusion imaging for preoperative evaluation prior to non-cardiac surgery. Journal of Nuclear Cardiology, Vol 19(2), pp. 277-284.