More than one in three areas of England restrict surgery for smokers and overweight patients

The Royal College of Surgeons (RCS) today warns smokers and overweight patients are becoming soft targets for NHS savings. A new report from the RCS has found that over one in three Clinical Commissioning Groups (CCGs) in England are denying or delaying routine surgery to patients – such as hip and knee replacements – until they stop smoking or lose weight, in contravention of national clinical guidance.

The RCS report ‘Smokers and overweight patients: soft targets for NHS savings?’ explores how widespread the practice of restricting surgery on the basis of weight or smoking status has become by examining the commissioning policies of CCGs in England. The report compares these against guidance produced by the National Institute for Health and Care Excellence (NICE), RCS and surgical specialty associations (SSAs).

The RCS found that over a third (34%) of the 200 CCGs that responded to FOI requests have one or more policies on BMI level or smoking status which stop overweight patients or smokers being referred for routine surgery. More than a fifth (22%) of CCGs are placing mandatory weight thresholds on referral to hip and knee replacement surgery – an increase on data acquired in 2014 [1]  which showed 13% of CCGs employed such policies.

Miss Clare Marx, President of the Royal College of Surgeons, said:

 “Public health programmes that assist healthy weight management and quitting smoking are fully supported by the College. Affected patients should be encouraged to attend these services while awaiting surgery. However blanket bans that deny or delay patients’ access to surgery are wrong. NHS surgical treatment should be based on clinical guidance and patients should be dealt with on a case by case basis. In some instances a patient might need surgery in order to help them to do exercise and lose weight.

“While it is difficult to categorically prove such policies are aimed at saving money, it is unlikely to be a coincidence that many financially challenged CCGs are restricting access to surgery. Our worry is that smokers and overweight patients are becoming soft targets for NHS savings"

“There is no clinical guidance from NICE, the Royal College of Surgeons, and other surgical associations to support mandatory bans for routine surgery on the basis of whether patients smoke or are overweight.”

The RCS says health ministers should make it clear that it is unacceptable for the NHS to ban or delay treatment on the basis of a patient’s weight or smoking status, unless this is backed up by evidence from NICE, a medical royal college or other medical professional association.

Several worrying CCG policies are highlighted in the report including Luton CCG which requires a patient’s BMI to be under 30 (the cut off for ‘obesity’) with mandatory referral to weight management services before any planned surgical procedure. East and North Hertfordshire CCG has a similar policy but with the caveat that if a BMI under 30 cannot be reached, patients can be referred to surgery if they manage weight loss of 10%.

North East Essex and Luton CCGs require patients who smoke to stop and provide evidence of this through attending smoking cessation programmes before any planned surgical procedure can take place. 13 CCGs (6.5%) have a policy which usually stops patients who smoke from receiving hip and knee surgery.

Mr Tim Wilton, President of the British Orthopaedic Association, said:

“There is no clinical, or value for money, justification for refusing to fund hip or knee replacements based on BMI or smoker status. Good outcomes can be achieved for patients regardless of whether they smoke or are obese, even at BMIs of over 50, and these surgeries are highly cost effective: typically delivering sustained pain relief for a cost that equates to just £7.50 a week.

“Hard-and-fast rules also undermine the NHS’s ability to involve patients in decisions about their own care, and are a distraction from the task at hand: making sure patients receive the best possible advice and care, to enable them to make the best possible decisions for their health – including losing weight and stopping smoking where appropriate. These comorbidity issues are best dealt with by appropriate informed consent and not by management dictat.”

• Royal College of Surgeons (2014) ‘Is Access to Surgery a Postcode Lottery?’

Notes to editors

The Royal College of Surgeons of England is a professional membership organisation and registered charity, which exists to advance surgical standards and improve patient care.

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