More than 80% of clinical commissioning groups (CCGs) now restrict routine surgery and other treatments for some patients unless they stop smoking or lose weight. Hip and knee replacements, fertility treatment and bariatric (weight loss) surgery are among the services affected.
Most referrals that I make to hospitals need to include information on smoking status and body mass index (BMI). For instance, a referral for physiotherapy is not accepted unless it includes BMI status. This is appropriate, as the outcome of this intervention is depends on many factors and the accepting clinician needs as much information as possible. However, with other treatments, a referral cannot be made at all if a patient’s BMI is over 30 (classified as obese) or they smoke. This criterion-based access applies only to routine and not emergency or urgent treatments.
Emily sees me for fertility advice. She is 35, a non-smoker with a BMI of 33. She has been trying to conceive for the past 18 months. I refer her for initial blood tests and a pelvic ultrasound scan, which are normal. Her partner, who is 38, has a normal BMI and has recently given up smoking through a pharmacy smoking cessation programme. Emily is keen for a joint referral to the local fertility services. However, with her raised BMI she does not meet the criteria for fertility referral to secondary care. Local recommendations by the CCG dictate that I should refer her instead to weight management services; if her BMI drops and stays under 30 for a period of six months, she can then be referred for fertility treatment. We have a difficult conversation. Emily is upset and very disappointed and, although she is motivated to lose weight with help, she believes that this delay will reduce her chances of conception considerably.
As GPs, we act as the patient’s advocate. But female obesity is linked to less favourable fertility and pregnancy outcomes. This is a two-fold problem: there is reduced natural ovulation as well as less chance of pregnancy, even with assisted conception. There are also higher rates of pregnancy loss after assisted fertilisation and implantation. Weight loss, on the other hand, normalises menstrual cycles and leads to spontaneous ovulation. If assisted conception methods are then used, these are also less likely to fail. If fertility treatments were offered to all women not meeting age, BMI or smoking criteria, budget constraints would restrict access for everyone or limit the number of cycles of treatment received.
Smoking cessation is the single most important lifestyle factor in disease prevention, improving health outcomes and reducing health inequalities. Where there is genuine clinical evidence that smoking is detrimental to the treatment being offered, it is preferable to withhold such treatment until the patient has stopped smoking. For instance, it would be wrong for a smoker to be placed on a lung transplant waiting list, as they would have a poorer prognosis following the transplant.
However, I believe that blanket bans on treatments by CCGs are wrong, as they take the decision out of the hospital clinician’s hands, and some reasons given by CCGs have a dubious evidence base, such as restricting cataract surgery to those with significant sight loss. Where patients are motivated to make lifestyle changes, they also have a right at least to be referred rather than refused by rigid CCG criteria. Obesity poses risks for patients during surgery and an anaesthetist or surgeon may believe that it would be too risky to proceed. The clinical pros and cons should be discussed with the patient. When a patient of mine with a raised BMI is unable to move from severe arthritis in her knees, any weight management referral is futile. Fortunately, I am able to refer her for a joint replacement and she has bilateral knee replacement, becomes free of pain and loses a little weight following surgery, through better mobility.
There are concerns that, with practice boundaries having been abolished, patients can choose to register in CCG areas that have less rigid criteria and this can lead to considerable instability within the NHS. It is true that we have the free will to make lifestyle choices if we are given the right support, but a refusal to offer a health treatment should not be on moral grounds, but based on clinical judgment from transparent, evidence-based medicine.