The Vale of York has been granted permission this week by NHS England to put fat people and smokers to the back of the queue for operations. Starting in January, their treatments will be delayed a year; the obese must lose 10% of their body weight, and smokers give up for at least two months.
The Royal College of Surgeons says it is “very disappointed that NHS England and No 10 seem to be backing this arbitrary policy”.
It’s always good advice to live healthily, but this crosses a new red line. The clinical commissioning group (CCG), which buys services for people in York and Selby, is the first to be given official permission, agreed by Downing Street, to discriminate against particular patients – something forbidden in the (non-justiciable) NHS constitution. But the CCG is in trouble, in July judged “inadequate” and put into special measures and prescribed a “financial turnaround” for its debts.
Rationing will always be a part of the NHS social contract. Every system in the world rations: just look at the strict limits in US health insurance policies. There never was, or can ever be, an instant, ever-open door – however much politicians pretend, with their impossible seven-day pledges on no extra money, that there can be. But the UK system is judged one of the most efficient in the world, getting the biggest bang for its modest bucks, spending less than similar countries.
The key is its unique gatekeeping GPs who dispense the great bulk of treatment, while the National Institute for Health and Care Excellence (Nice), devised by the last Labour government, judges which drugs and treatments are good enough value for money for the NHS. The rule of thumb is to spend up to £30,000 for an extra year of good quality life.
Right from 1948, when the NHS was first set up, waiting lists were the traditional rationing mechanism. When governments tightened spending, waiting times grew, which was good for surgeons’ private practice.
For the first time in history, the last Labour government all but abolished waiting lists, something seasoned NHS experts never thought possible. With a spending increase of 7% a year, new targets saw waiting times drop from sometimes two years to just 18 weeks maximum, and two weeks for suspected cancers. Surgeons’ incomes plummeted, as did payments for private healthcare.
But in the present crisis, rationing is tightening everywhere. You get only one cataract fixed where CCGs think one eye is enough. The list of treatments being struck off is lengthening, and the postcode lottery of what your CCG pays for produces injustices.
I reported recently on a podiatry clinic treating severe diabetics that can give some patients a cast that cures ulcers in eight weeks. Those in other CCG areas get a cheaper bandage, which means healing takes 52 weeks. In the past, old people were often denied many life-enhancing treatments. All such rationing may be unfair, but at least it was never personal.
The abiding principle was that the NHS treated people in order of medical need, according to resources available. Minor complaints went to the back of the queue. Urgent cases were treated first, followed by those people likely to be rendered wheelchair-bound and needing social care if they did not get surgery on hips or knees – as will many of these obese patients.
The system was blind to everything but medical priority, a founding NHS principle that treated viscount and vagrant according to urgency, priest and sinner in next-door beds regardless of rank or virtue.
But once a patient’s personal failings can be taken into account, where does that lead? More people on low incomes are obese and smoke, and therefore already suffer worse health. This is for a host of psychosocial reasons, including the sheer stress and hardship of being at the bottom. (See Michael Marmot’s work, or the irrefutable evidence from Richard Wilkinson and Kate Pickett, authors of The Spirit Level, on the link between low status and poor physical and mental health.)
The poor often get worse NHS treatment, having less sharp elbows, and living in areas where the best doctors are harder to recruit. Undoubtedly most will have tried to lose weight and quit smoking, but public health budgets for obesity and smoking programmes have been cut, and are set to shrink again. This blaming of the individual conveniently shuts out social context. Don’t they have free will, these people? Politically, they will be easy to cast to the back of the queue, shamed into silence for their fatness and addiction. They will make much less fuss than local campaigners against any closures to hospital units.
This opens up new horizons: how much easier rationing becomes when we can blame the patients. Hey presto, waiting lists can be pared right down, targets hit, leaving only the virtuous on the lists.
But who are they? Let’s weed out anyone in any way responsible for the burden they put on the NHS. Away with the boy racers smashing themselves up with their first motorbikes and cars. Out with the extreme sports addicts – the climbers, potholers, boxers, base jumpers paragliders, skiers and F1 drivers, who get their adrenaline kicks at the NHS’s expense. Forget all sports injures.
Away with my own age group, too: drinking too much wine of an evening, slowly corroding our livers: a host of cancers are caused by drink and diet. And what about people bitten by their own horrible, fierce dogs? Or idiots tripping over while texting on smartphones?
As Hamlet said, use every man after his desert (or perhaps desserts) and who shall ‘scape whipping? Until now, in the NHS, the service may have creaked under the strains of the worst funding crisis in its history, but the quality of mercy was not strained. That has been the NHS’s great moral strength, as with the Red Cross or Médecins Sans Frontières, or indeed the Hippocratic oath itself. In treating the sick, let there be no discrimination over their moral worth.
Sending fat smokers to the back of the queue is a betrayal of NHS values| Polly Toynbee
