Denying joint operations to obese patients is counterproductive

We fear that there are going to be many more stories such as this about the National Health Service before the wounds of a decade of underfunding followed by the coronavirus pandemic start to heal.

Rebecca Thomas, our award-winning health correspondent, reports today that obese patients are being denied life-changing hip and knee replacements, and being left in pain as the NHS attempts to cut costs.

One-third of NHS areas in England and some health boards in Wales are refusing joint replacement operations to patients who exceed a given body mass index. This is contrary to guidance from the National Institute for Health and Care Excellence (NICE), the body responsible for deciding whether treatments are value for money.

Of course, as long as healthcare is rationed, difficult choices will have to be made. And the blunt truth is that all expensive treatments on the NHS are rationed, as they have to be in a system of limited resources. Instead of being rationed by ability to pay, the usual mechanism for rationing in the NHS is queueing. At the same time, however, treatments are also rationed by need, and it is the role of NICE to help to decide which groups of patients should be prioritised over others.

We can understand why some parts of the NHS might de-prioritise obese patients for hip and knee replacements. It might be argued that obesity is the cause of joint problems and that therefore treatment should focus on weight loss, or else the problems are likely to recur with the artificial joints.

But the NICE guidelines recognise that causation may not be all one way and that for many patients joint problems contribute to obesity rather than the other way round. In which case, joint replacement is the key to reducing weight, allowing patients to exercise more.

This is a field of healthcare undergoing rapid transition, as the availability of weight-loss drugs such as Ozempic has changed the options available to patients, offering hope of treatment without surgery. But it remains important that overweight patients do not face a sweeping ban on joint replacement operations on the basis of arbitrary body mass index counts – especially as these BMI limits vary from area to area across the NHS.

It is devoutly to be wished that this new government is beginning to turn the NHS round. Rachel Reeves, the chancellor, will confirm at the spending review on 11 June that the health service will be allocated substantial increases in resources over the next four years.

Wes Streeting, the health secretary, has already taken the risk of overclaiming the improvement that has been made in just 11 months since the election. He claimed that waiting lists had fallen for six months in a row, only for the latest figure, for month seven, to show a small increase. His claim of having met his target for the number of new appointments “seven months early” was undermined by figures obtained by Full Fact, the fact-checking charity, suggesting the rate of increase has in fact been slower than last year.

We hope that resident doctors will vote against strike action, in order to allow these early, if overstated, signs of improvement to turn into real progress.

In the meantime, difficult choices about whom to treat, and whom to treat first, will continue to beset the health service. In making those decisions, doctors must avoid unfair and discriminatory blanket bans based on arbitrary weight limits.