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Rationing of joint replacements raises fears of further cuts

BMJ 2005; 331 doi: https://doi.org/10.1136/bmj.331.7528.1290 (Published 01 December 2005) Cite this as: BMJ 2005;331:1290
  1. Rebecca Coombes
  1. London

    A decision by NHS trusts in Suffolk to deny replacement joints to obese patients has led to concerns that other financially stretched NHS trusts could take similar steps to ration treatment.

    As part of a series of new “thresholds” to treatment, three primary care trusts in east Suffolk—Ipswich, Suffolk Coastal, and Central Suffolk—have announced that patients will no longer be considered for hip or knee joint replacements if they have a body mass index (BMI) >30.

    The list of thresholds was drawn up by a group of consultants who carry out the procedures at Ipswich Hospital and local GPs, led by Brian Keeble, director of public health for Ipswich Primary Care Trust.

    Dr Keeble said that serious financial pressures were behind the decision: “We cannot pretend that this work wasn't stimulated by the pressing financial problems of the NHS in east Suffolk.”

    The NHS in east Suffolk is under pressure to eliminate a £47.9m ($83m; £70m) deficit by the end of the financial year.

    But the BMA criticised the new criteria. Jonathan Fielden, deputy chairman of the BMA's consultants' committee, said: “The decisions on whether patients should receive treatment should always be based on clinical need and not solely financial reasons. Clinical guidelines are often drawn up to ensure patients receive safe, high quality, appropriate treatment, but there must be a facility to consider each case individually.”

    He warned that these situations could be repeated around the country as “as market based health care is introduced to the NHS.”

    David Dandy, vice-president of the Royal College of Surgeons, questioned the clinical basis for excluding obese people from surgery. Mr Dandy, an experienced knee surgeon, now retired, said a BMI of 30 was too low a threshold to exclude a patient from surgery.

    “By setting the limit at 30 you are eliminating about half the population. It is too low to exclude someone for clinical reasons. There is no hard evidence that obesity makes any difference to overall outcomes of surgery. If you are in severe pain, you are in severe pain. It's not humane to say we can't help you because you are not in the band of normal weight.”

    However, Christopher Bulstrode, professor of trauma and orthopaedics at the University of Oxford, said he did not do hip replacements on patients with a BMI >35 if he could avoid it.

    He said, “Obese patients are very difficult to operate on when doing a hip replacement because the weight tends to go on around the hips. This means that we have to make a longer incision to get down to the hip, so they lose more blood. There is also more dead space when we close, which could act as a locus for infection, so they tend to get infected more often. So my own personal experience is that the operation takes longer, the anaesthetic takes longer, the bed stay is also longer, and the complication rates are higher.”

    The new thresholds introduced in east Suffolk also cover treatment for nine other conditions from varicose veins to inserting grommets for glue ear in children.

    However, a spokesperson added that the thresholds were not “set in stone” and that clinicians were able to make decisions that were based on the circumstances of individual patients.

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