Where will NHS rationing end if we weigh in against fat people?

Published on 27/11/2005 02:08

SO LET'S get this straight. Dissolute footballer George Best was entitled to a liver transplant on the NHS in 2002, despite his transparent determination to drink himself to death. But obese people in East Suffolk are to be refused hip and knee replacements, even if they are in terrible pain, as a result of healthcare rationing.

It's not as if we are talking about people who are can't-get-out-of-bed-without-a-crane fat. The area's three primary care trusts have said there will be a blanket ban on such operations for people with a Body Mass Index of 30: that's a woman who is 5ft 2in and weighs 12 stone or a man who is 5ft 10in who weighs 15 stone.

And it's not a question of surgery being denied for clinical reasons. Although hip and knee replacements are less likely to be successful in overweight patients, Dr Brian Keeble, director of public health in Ipswich, has been clear that the motive behind the decision is primarily financial. The trusts need to get rid of a 47.9m deficit, and apparently believe fat people are fair game.

The thing is, they're probably right, because according to a survey of 2,000 people published by BUPA last week, more than a third of the population is in favour of charging the obese (and, to be fair, smokers and heavy drinkers) for what they consider to be self-inflicted illness.

Despite the fact that one in two Britons is now overweight and one in five is obese, intolerance of fat people is the last socially acceptable form of prejudice. Indeed, public distaste for those of larger proportions is so entrenched, it is often shared by fat people themselves. So where other oppressed minorities will campaign for their rights, the obese tend to feel ashamed, and accept the abuse they suffer in silence.

(Witness the fact that support groups for fat people are more likely to focus on the drive to get slim than on lobbying airlines for larger seats to accommodate larger bottoms.)

While alcoholism and drug addiction are now recognised and treated as illnesses, fat people continue to be perceived as greedy and indolent pariahs, who refuse to exercise any self-control over their eating habits.

Obsessed as we are by political correctness, it seems strange we should have little sympathy for the overweight, particularly given the fact that it is increasingly clear that, in the West at least, obesity is linked to socioeconomic deprivation. Anyone who doubted this need only have glanced at footage of the hordes of people stranded in New Orleans after the hurricane: predominantly poor, predominantly black, and predominantly supersized.

Despite this, the sight of a truly obese person is likely to provoke either a feeling of revulsion or a voyeuristic C4 documentary entitled Johnny Goes to Fat Camp.

There is already clear evidence to show overweight people are discriminated against in the workplace, both in terms of getting jobs they apply for and in the pay they receive for the work they do.

But studies show they also fare badly in terms of healthcare, partly because of the tendency of GPs and nurses to assume their condition is related to their weight problem, and partly because the possibility they will be judged makes them too embarrassed to seek help. Yale psychologist Kelly Brownell points to surveys in which almost a quarter of nurses admitted they were repulsed by obese people. Attitudes expressed by doctors included: "Obesity is caused by character flaws and a failure to lose weight is due only to non-compliance."

Around 17% of GPs admitted they were less likely to carry out pelvic floor examinations on very obese women and more than 80% were reluctant where the woman herself was hesitant. Brownell also gathered evidence that overweight people regularly miss crucial check-ups.

Almost a third of women with a BMI of over 27 and 55% with a BMI of over 55, for example, had delayed or cancelled appointments because they knew they would be weighed.

Obese people are already marginalised when it comes to their health. To stigmatise them further - by ruling them out of fairly routine operations on the grounds of weight - can only have a detrimental effect on their health and self-esteem. Since the cost of going private (a hip replacement costs 7,000-9,000 and a knee replacement 8,000-10,000) is beyond the reach of most people who need to, such a move also condemns them to a lifetime of pain.

Of course, NHS resources are finite, and, unpopular though the idea is, some degree of rationing is a fiscal necessity. For this, and to control waiting lists, it may be appropriate to look at whether a particular operation is the correct course of action for a particular individual, taking into account their age, weight and personal circumstances.

But such decisions should be made on a case-by-case basis, in the same way as liver transplants such as Best's. In those instances where obesity is impeding surgery, the excess weight should be seen as a temporary hurdle the patient can overcome with support, rather than another 10,000 saving to celebrate.

When making these difficult judgments, it is important for primary care trusts to remember that fat people pay taxes too. After all, it is one thing to insist everyone should be required to give a portion of their income to fund services they may not use (such as education or improved transport networks), it is quite another to demand people pay for a service they will be denied when they need it.

And if we decide the best way to cut costs is to punish people for "self-inflicted" conditions, where is the blame game going to stop? Could we see health authorities refusing to treat people who are sexually promiscuous for STDs or those who use sunbeds for skin cancer?

Perhaps those in the throes of a heart attack should be interrogated on their diet before an ambulance is dispatched and anyone who fails to do pelvic floor exercises after childbirth should surely have to thole that self-inflicted prolapse. Indeed, if fat people are refused treatment for fat-related conditions, why shouldn't sports fanatics be denied treatment for sports-related injuries?

The point is we are all fallible: we all make choices every day that impact on our health, from eating junk food to having children. And unless we are willing to sacrifice our own right to NHS treatment when the time comes, we should not be so hasty in judging other people's lifestyles, and finding them wanting.