Britain Declares - NHS Limits on Fat People
U.K. curbs care for fat people
Local health authority near London says obese can't have hip or knee replacements
Ipswich doctor cites financial constraints, says tight budget better spent on slimmer patients
Dec. 17, 2005. 01:00 AM
CAROLINE MALLAN
SPECIAL TO THE STAR
London—Britain's cherished universal health-care system has started denying treatment to fat people.
The first official move to refuse surgery happened last month when a local health authority in Ipswich, northeast of London, announced that obese people would not be given hip and knee replacements.
The move, which has been met with both praise and condemnation, comes amid a story all too familiar to Canadians — hospitals facing cash shortages at a time when the population is both growing and aging.
Dr. Brian Keeble, head of public health for Ipswich, acknowledged that while the added risks of hip and knee surgery on obese patients were a factor in the move, so was the reality of limited resources.
"We cannot pretend that this work wasn't stimulated by pressing financial problems," Keeble said in a statement of the list of services being reduced to save money, with joint replacements being the most controversial.
Keeble added that given the increased failure rate of the procedures on overweight people, the limited amount of money available is better spent on slimmer patients.
The Ipswich group has set a body mass index of 30 — the World Health Organization's definition of clinical obesity — as the threshold at which surgery will be denied.
Currently, one in five men and one in four women in the U.K. are obese.
Michael Summers, chair of Britain's Patients Association, a charitable advocacy group, said the move amounts to discrimination.
"Obese or large people are as entitled to these surgeries as anyone else because they pay for the NHS (National Health Service) just like everyone else does," he said of the taxpayer-funded health-care system set up in 1948. Along with social assistance, it's a key part of Britain's welfare state.
"It is meant to be available to all; that was the entire premise. And one might argue the elderly in need of hips and knees are even more deserving because they have been paying for it even longer," Summers said of the system.
The surgery limit has also ignited debate on whether or not smokers suffering from lung ailments will be the next group to be denied treatment if they refuse to kick the habit, and whether this trend amounts to an attack on the poor, who have rates of both smoking and obesity much higher than middle- and upper-class Britons.
"It's a slippery slope and it's not what doctors are supposed to be doing with their time," Summers said of putting physicians in the role of judge.
But Tony Harrison, of the independent London think tank the King's Fund, said the move amounts to a good dose of common sense given the reality of limited resources.
"Rationing is a reality when funding is limited," Harrison said, adding responsible health-service providers have an obligation to taxpayers to get the most benefit out of the money they're given.
Harrison said the lower success rates for hip and knee replacements in obese patients cannot be ignored.
"Ability to benefit is a key criteria. It is a valid point. If chances of successful outcomes go down, you are wasting money."
The move is also tacitly supported by the government body charged with giving guidance to local health authorities on what they should fund.
While stating in a new report that income, class or age should not be factors in deciding treatment, the body, known as NICE (National Institute for Health and Clinical Excellence), leaves room for doctors to deny treatment based on cost.
"If, however, self-inflicted cause/causes of the condition influence the clinical or cost effectiveness of the use of an intervention, it may be appropriate to take this into account," it states.
In a scenario mirrored in Ontario in recent years, the Labour government of Prime Minister Tony Blair has poured money — raised through a dedicated tax — into the health system amid election promises to dramatically reduce wait times for a host of procedures.
While most agree that the system has improved dramatically as a result, local hospitals say they are being forced to make cuts in some areas in order to deliver on wait time promises in others.
In Canada, federal Health Minister Ujjal Dosanjh hailed standardized wait times agreed upon last week, which sets 26 weeks as the maximum time a person should be expected to wait for a new hip or knee.
There are currently no formal weight restrictions for the procedure in Canada, although it is not unusual for a doctor to advise a patient to lose some weight before the surgery in order to reduce the risks associated with the anaesthetics used and to speed recovery.
Dr. Peter Schuringa, president of the Ontario Orthopedics Association, said Canada should not take any lessons from the British attempt to ration health care based on a patient's lifestyle.
"Before we start telling people they cannot have a procedure because of how much they weigh, we've got to find more creative ways to improve the system and to finance more procedures," he said in a telephone interview from Kitchener.
Schuringa stressed that finding new ways to fund more procedures in Ontario needs to happen without punishing patients for being overweight.
"That's a very complicated issue, in part because people's ability to exercise and lose weight is often severely compromised if they are suffering from arthritic knee or hip joints," he said. But he added that patients awaiting joint-replacement surgery are often advised to lose weight before their operations
Most doctors also believe that replacement joints last longer if patients are of normal weight. Schuringa noted that may reduce the need for future surgery, saving patients pain and stress and the health-care system money.
In Britain, the debate over how much patients can reasonably expect of a taxpayer-funded health-care system has been raging in recent weeks over both the joint-replacement issue and the death of soccer legend George Best. An alcoholic, he received a liver transplant in 2002, but fell off the wagon after his surgery and his health declined, leading to rejection of the liver.