Thursday, 26 October 2017

Denying healthcare to smokers and fat people

I wrote this last week about the latest attempt by an NHS trust to defraud its customers...

In 1948, the minister for health, Aneurin Bevan, outlined the three guiding principles of the NHS: that it meets the needs of everybody, that it is free at the point of delivery and that it is based on clinical need, not ability to pay.

There was no footnote saying ‘…but only if you lead a state-approved lifestyle’. Bevan’s vision for the NHS could not have been clearer and yet a growing number of NHS trusts have been flying the kite of discrimination against smokers and the overweight. Hospital mandarins in North Yorkshire toyed with the idea of refusing surgery to incorrigible smokers and obese people last year. Clinical commissioning groups in Hertfordshire raised it again this week. Both sets of bureaucrats said that they would make an exemption for life-saving surgery, which was nice of them, but if patients are merely suffering from chronic pain, they will have to stop smoking and lose weight.

It is true that some operations will be more successful if the patient is slim and doesn’t smoke, although these benefits are not as great as some NHS bosses imply. But the risk is to the individual and it is the individual who is going under the knife. More importantly, it is the individual who has paid for the treatment.

The per capita cost of the NHS to every man, woman and child in Britain amounts to £2,000 per annum. If the average citizen had to write a cheque out for this amount every year, we might more fully appreciate the fact that the NHS is not a ‘free’ service that our masters can ration out to us if they approve of our lifestyles. It is an industry. We are the customers and those who work in it are our servants. Too many people at the top of the NHS hierarchy seem to have forgotten this. Increasingly, they see it as a tool of social control.

Some years ago, the NHS made a television advert which ended with the slogan ‘If you smoke, you stink’. It is difficult to imagine a private enterprise wilfully insulting a quarter of its clients in such a way. The demonisation of smokers and, more recently, fat people has given the NHS two groups of scapegoats to blame for its own shortcomings. We are routinely told that obesity threatens to bankrupt the NHS. This would be nonsense even if it were possible for the NHS to go bust, which it isn’t. The figures do not add up. Nor do the sums add up for smoking and drinking, neither of which are a ‘burden on the NHS’. Tax revenues from tobacco and alcohol amounted to £24 billion last year, vastly exceeding any associated costs to the health service.

If the NHS no longer wishes to treat smokers then it is only fair that they be given a refund, starting with all the tobacco duty they have paid over a lifetime. This alone would be enough for them to afford world class healthcare, with the added bonus that they would no longer have to pay for their own vilification.

Bevan understood that there is a basic social contract at the heart of the NHS. Because we are not allowed to opt out of paying for socialised medicine, doctors are not allowed to opt out of giving us it. No taxation without medication. If you’re going to start making patients go without treatment or pay privately just because they did not go everything they could to avoid their ailments, you might as well have a healthcare insurance system.

Such systems work well in the rest of Europe and I would not be opposed to borrowing a few ideas from places where health services produce better outcomes. The people who should really be concerned about the move towards NHS rationing are those who want to preserve ‘our NHS’ because they mistakenly believe that it is the envy of the world. Such a fundamentally political project cannot survive without consent. If it is going to start defrauding its customers - what else can you call refusing to deliver a service that has been paid for? - it is bound to lose public support.

If we set down this path, there is no obvious end to it. There are thousands of avoidable risk factors for diseases, accidents and injuries. Should we deny treatment to all those who fail to avoid them? Perhaps the NHS should simply adopt a policy of only treating healthy people. After all, if it wasn’t for the patients, the system would work perfectly.

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