Ah...the New Year.
January and February are the time of year that teaches a non-drinker what a hangover feels like. The skies are grey, the air is chill, the creme eggs are in the shops and the papers and TV are full of advertisements and articles urging us to reject the Christmas binging, ‘detox’ and adopt a new healthy lifestyle.
On a similar theme, this month the news was full of the Hertfordshire GP consortia who have insisted that obese patients cannot be placed on waiting lists for routine operations (such as hip and knee replacements or gall-bladder surgery) unless they lose weight. In fact, this approach is not new, last year NHS Kent directed their GP’s to ensure that smokers referred for routine surgery completed a 12 week smoking cessation course prior to being placed on the waiting list.
This has set me thinking. Is it possible that a similar approach could ever be applied within cancer care? Could this ever be justifiable?
The foundations to support such a policy are, of course, already in place with last year’s refreshment of the Cancer Plan ‘Improving Outcomes: a strategy for cancer' being very focussed on health promotion with explicit links made between cancer prevention and lifestyle. This states that up to half of all cancers could be prevented by reductions in smoking, alcohol consumption and levels of obesity as well as improvements in diet, and increased levels of exercise. The emphasis is on educating people to change lifestyles and ‘assisting people to make healthy choices and hence more ‘carrot’ than’ stick’.
The government has ‘upped the ante’ on this issue recently by releasing a report via the NHS Future Forum that health workers should ‘make every contact count’ and discuss with patients four main lifestyle risk areas; diet, exercise, alcohol consumption and tobacco use, and encourage healthy behaviours.
Of course I realise that in the UK, as in most countries, health care generally, and cancer care specifically does need to be ‘rationed’. By this I mean that not every person with cancer can, or should, receive very expensive drugs or treatments just because they are available. A case needs to be made for her the effectiveness of the drug based on likely benefits to population as a whole versus the cost of providing it to all patients who may benefit. These decisions on rationing based of effectiveness and cost are different from rationing based on patient lifestyle.
So, how close are we to a position, where in a health system with limited funds and ever increasing treatment costs, treatments are declined to people who ‘fail’ to make the right choices? Where cancer treatments are declined to smokers with lung cancer, breast cancer patients who are obese and colorectal cancer patients who do not eat enough fibre?
I hope we never reach that point. The reasons why people fail to make the ‘right’ choices are very complex. Many patients suffering the long-term effects of smoking were ill-informed when they began and hopelessly addicted later on. People suffering genuine hardships are often loath to give up the habits which make their lives bearable. The advice around what constitutes a healthy diet is often changeable, unclear and some of the constituent parts of it, for example, fresh fruit and vegetables are relatively expensive for those on limited, or often very restricted, budgets.
I think there is a real difference between encouraging patients to adopt a healthier lifestyle for real benefits (for example encouraging patients with a treated head and neck cancer to stop smoking in order to reduce chance of recurrence) and alienating distressed patients by being critical of past choices or using withdrawal of treatment as a threat or incentive.
Good luck with those resolutions!
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