Is the NHS Fattist
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New research could be set to turn CCG and Health Board policy on its head. Currently, many overweight or obese patients needing hip or knee replacements are being refused surgery until they have lost weight. This new data has shown that even if a patient is obese, it has NO effect on the outcome of a hip or knee replacement.
The study, presented by 21-year-old Olivia Roberts from Cardiff University Hospital at the All Wales student research symposium run by the Royal College of Surgeons of Edinburgh challenged the existing postcode lottery policy which is based on the false assumption that obese patients had worse outcomes than their slimmer counterparts.
Olivia showed that the extent of the obesity had no effect on joint improvement, either THR or TKR, did not impact on the length of hospital stay and made no difference to post-operative complications.
Many CCGs refuse obese and morbidly obese patients access to TKR and THR unless they can demonstrate that they can lose weight - the theory is that obese and morbidly obese patients have worse outcomes due to their weight and therefore cost the NHS significantly more.
Data from a recent report (Is Access to Surgery a Postcode Lottery) showed some shocking results in England: of most concern is that 44% of CCGs (23 of 52) had only arbitrary referral criteria in place. These policies broadly require patients to lose weight before surgery. Such criteria are in explicit contravention of NICE and surgical commissioning guidance, and have no clinical justification in being applied to a general population.
Seven CCGs have a policy which specifically requires patients to be below a certain BMI or to have demonstrated weight loss. For example, Sandwell and Birmingham CCG’s policy states that referred patients should have a BMI of below 40kg/m2 or, if above, that the patient has reduced their body weight by at least 10%. Coastal West Sussex and Gloucestershire CCGs have criteria relating to both hip score and BMI.
The clinical guidance is clear that obesity should not be a barrier to surgery. According to the British Orthopaedic Association (https://www.boa.ac.uk/), there is no consistent evidence that patients with a high BMI who undergo hip replacement surgery do better or worse than other patient groups.
As a clinician, I find it unacceptable that necessary healthcare is being denied to some patients, depending on where they live," said Olivia, "This research has shown that there is no clinical reason for joint replacements being withheld based on BMI alone."
In Wales, Health Board policies vary but include e.g. Betwys y Coed policy which stipulates a BMI less than 35 and Cardiff whose policy is to enforce weight management on patients with a BMI over 40 before elective surgery, whilst a survey by the Welsh NHS Confederation showed that only 4 in 10 people thought that weight should impact on treatments received.
The BOA has said that weight should not be used as a criterion to refuse or delay referral to surgery for patients who may be in extreme pain with advanced arthritis. Doing so, it says, ‘may be unethical’. Similarly, NICE guidance says that ‘patient-specific factors (including age, sex, smoking, obesity and co-morbidities) should not be barriers to referral for joint surgery.
"Research like this which could result in better patient access to the correct healthcare is vital, " said Mr Steven Backhouse, ENT Consultant, Princess of Wales Hospital, Director of the RCSEd advisory network group and convener of the All Wales Research Symposium,
"Challenging healthcare policy can be very difficult, but this kind of data deserves close attention and could change the way we offer surgery to patients in the future."
"As a surgeon, it's my view that the most important consideration is the outcome and quality of life for the patient," said Mr Peter Lewis, Consultant Orthopaedic Surgeon, Prince Charles and Royal Glamorgan Hospitals, "Unless the extent of the obesity impacts on my ability to actually do the surgery then I would help any patient who I feel would benefit, independent of weight."
"This is one of the many research programmes supported by the RCSEd outside of Edinburgh, " said Professor Iain Ritchie, President of the RCSEd, "As one of the oldest surgical colleges in the world, we have 22,500 professionals in almost 100 countries worldwide, so these programmes are a vital part of our professional support".
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