Sunday, 19 December 2010

A rock and a hard place

There is no doubt that patients’ lifestyles influence their state of health. Their dietary habits, alcohol consumption, smoking and sexual practices are the main, but not only factors in this. To doctors this is of limited relevance. Certainly we should adopt a preventive role in advising our patients of their lifestyle practices that can potentially impinge on their health, but even this has it’s limits. While no-one would argue that we should encourage our patients to stop smoking, how many doctors would advise patients to give up horse riding (128 deaths/yr per 100,000 participants) or other risky sports.

By the time patients present to us with the consequences of a lifetime of bodily abuse however lifestyle becomes unimportant when it comes to treatment options. At this stage we simply have to treat to the best of our ability. This is crystallised by the GMC good practice guide at para 7; “You must not refuse or delay treatment because you believe that a patient's actions have contributed to their condition.” and “You must not unfairly discriminate against them by allowing your personal views to affect adversely your professional relationship with them or the treatment you provide or arrange.  This includes your views about a patient's age, colour, culture, disability, ethnic or national origin, gender, lifestyle, marital or parental status, race, religion or beliefs, sex, sexual orientation, or social or economic status.”

So what do you do when your Trust proposes to engage in precisely that sort of discrimination as is happening here, and is going to require your co-operation to apply it. To co-operate puts you in breach of GMC good practice guidelines, while to defy puts you most definitely in the firing line as far as your employer is concerned.

The GMC does seem to have this covered as they state; “If inadequate resources, policies or systems prevent you from doing this, and patient safety is or may be seriously compromised, you must follow the guidance in paragraph 6.”
So what does it say at paragraph 6? This is where suddenly the crystal clarity suddenly deserts the GMC and they are a little more wooly” you should draw the matter to the attention of your employing or contracting body. If they do not take adequate action, you should take independent advice on how to take the matter further. You must record your concerns and the steps you have taken to try to resolve them.”  Firstly you are supposed to stick your head above the parapet and start making a fuss. And when, inevitably, your expressed concerns are ignored then what. Then all of a sudden it is for someone else (unspecified) to advise you. What a cop out. The logical next step of course is whistleblowing but as I have pointed out before this is likely to have catastrophic repercussions, despite the presence of legislation supposed to protect you. 

And when your Trust turns on you like a rabid psychotic dog, because you have followed GMC guidelines, just how much support do you suppose you will get from the GMC?


  1. NHS Kent is following the lead set by NHS Surrey. See here:

  2. What a bunch of complete t***s! These same idiots, are those that tell fat people it's all their own fault, for not adhereing to a diet, high in carbs that will almost certainly, consign them to fail in their endeavours.

    They no doubt too have whole departments dedicated to sport injuries, all paid for on the NHS. Hypocrasy of the worse kind sums up the Health Gestapo, these scientifically challenged apparatchiks of the NHS. Unproven theory becomes accepted fact, with no evidence base to substantiate advice.

    Sure, smoking is bad for us, which I accept, but not so long ago GP's told us to smoke to 'relax'. Hectoring and invective is not the way to change habits and the 'rubbish' we are told in relation to diet and lifestyle does not add to the sum of knowledge needed to challenge society'a ills. That is why little of what we are told about health, is treated with any credibility by Joe Public, and rightly so.

  3. Absurd. The Trust I'm sure would point out that they have a whistleblowing policy which would doubtless promise the world.

    One point to make is that fat/obese people and smokers do have higher rates of complications post-surgery and tend to take longer to recover. I do of course think they should be treated regardless.

    However, there are many situations in which payments to hospitals are reduced if there are complications post-op - under the brave new white-paper world, if one of your obese patients has an op, goes home, and comes back with a DVT, you don't get paid for that readmission, or if your smoker comes back in with a pneumonia the same applies. Easy solution is to keep them in longer - but with the cuts in nursing staff and the reduction in the quality of those staff, as highlighted by any number of blogs and indeed by the Royal College of Nurses, and the reduction in beds generally, you might not have that option.

    On top of that I imagine managers are starting to think about the loathsome hospital ratings systems the government are backing (I'm looking at you, Dr. Foster) and thinking hey, if we stop smokers and fatties (sorry) from having their ops our complication rates are going to look a load better than the hospital down the road who're choosing their patients based on good old-fashioned clinical need.

    Our position as doctors is I think clear - but in a situation where managers have as their drivers the need to reduce inpatient stays, postop complications, and readmissions, and the need to think about how they're going to attract business, you can see why they're suggesting it.

    I'm not saying what the Trusts are doing is right. But the management are paid to play a game, and it seems to me that it may be the rules of the game, which are set by the government, which are the problem.