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Should GPs assign patients to weight loss management before surgery?

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Recently I was talking to a friend of mine who lives in Spain, and he told me of the success he's had at losing some weight. He decided to count his calories – cutting out bread, potatoes and alcohol as part of his self-imposed diet – and do mild exercise in the form of walking three to five miles a day. Following this plan in the month of November, he's lost 10 kilograms and is now on the upper edge of a satisfactory BMI.

We'd arrived at the subject of weight loss while we were discussing the restriction of health services to overweight patients. My friend's view is that if you want something badly enough, you'll simply do it. He'd been on a trip to Granada, with plenty of walking, and had found he was getting out of breath and feeling bloated all the time. He didn't want to continue feeling like this, and so decided to do something about it. He's also due to become a grandfather in the New Year, and didn't want to be 'the fat grandad'.

However, he understands that not everyone has the same willpower. So, he applauds the move by some CCGs to ask GP practices to offer help to patients who need to lose weight before surgery. However, he wonders if this is a step closer to 'service rationing' and might be a way of controlling budgets rather than tackling underlying health issues.

Are CCGs underhandedly service rationing?

A report from the RCS in April said that smokers and obese patients have become soft targets for CCGs looking to save money. The report found that a third of CCGs then had policies in place which link BMI to delivery of routine surgery. This number has undoubtedly increased since.

Surgeries that fall under these edicts include hip and knee replacements. The upper BMI limit in many CCGs for acceptance for surgery is 30.

The RCS president, Clare Marx (CBE DL PRCS) said, "While it is difficult to 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."

Cash-strapped Harrogate and Rural District CCG restricts surgeries for obese patients

Harrogate and Rural District CCG is one of the most recent CCGs to request that its GP practices offer a referral for a six-month weight management programme to patients with a BMI over 30.

The CCG is struggling with a deficit expected to stretch to £8.4 million in the current financial year. It is also less 'secretive' of its reasons than others have been. While stating that the measure does not say that patients cannot have surgery (and emergency procedures will be undertaken in any case) the CCG's CEO, Amanda Bloor said, "By introducing a six-month health optimisation period, we are encouraging and supporting patients to undertake a lifestyle change which will provide them with the best possible clinical outcome."

Financials, morals, and ethics

The views on these policies vary wildly, especially in such a financially difficult environment. Some argue that treatment of obese people, where surgery and long-term outcomes will be affected by their weight, simply cannot continue without some restriction. It puts an ongoing financial burden on the CCG.

Others argue that it is both morally and ethically wrong to deny patients surgery based upon a blanket restriction on a measurement of BMI.

Clare Marx is definitely of this opinion. She says, "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 may need surgery in order to help them to do exercise and lose weight."

It's a perplexing situation, and one that the NHS and its CCGs are struggling to define across the board. Meanwhile, it appears that GPs will once more be put in a difficult position.

How do you explain that one patient can have treatment because their BMI is 29, while the patient next in line can't because they are considered obese with a BMI of 30? It looks like accurate measurement of weight and BMI is going to be key to those conversations and treatment referral going forward.

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