The first evidence that financial problems in the NHS are forcing trusts to ration operations came yesterday with an announcement that overweight people in East Anglia will be denied replacement joints, even if they are in serious pain.
East Suffolk primary care trusts said patients will no longer be considered for hip and knee replacements at Ipswich hospital if they have a body mass index of more than 30, the clinical definition of obesity.
Brian Keeble, director of public health, said: "We cannot pretend that this [decision] wasn't stimulated by the pressing financial problems of the NHS in East Suffolk." Local doctors supported the move because the risks of operating on overweight people were higher, but the motive for the new thresholds was "unashamedly financial."
The trusts had to do everything possible to eliminate a £47.9m deficit by the end of March, he said. The move follows the disclosure in the Guardian last week that Patricia Hewitt, the health secretary, has decided to enforce a policy of zero tolerance of deficits in the NHS to squeeze out a forecast overspend of up to £700m across England.
Her move is forcing a financial squeeze on hospitals and primary care trusts, whose boards thought it was impossible to break even without unacceptable cuts in service. The trusts were told months ago to make savings by improving productivity, but those that have not done so must now consider a winter round of ward closures, staff cuts and delays in patients' appointments.
Dr Keeble said talks with local consultants and GPs about restrictions on operations in East Suffolk began last year. Under the new rules, no patient will be allowed to have a hip or knee replacement unless their pain and disability is "sufficiently significant to interfere with daily life". Consultants will not consider operating unless painkillers, physiotherapy and non-steroidal anti-inflammatory drugs have failed. But even in those cases "surgery will not be performed unless the patient has a body mass index below 30".
This would rule out a man of 1.55m tall (5ft 10in) who weighed more than 96.15 kilos (15st 2lb), or a woman of 1.53m (5ft 3in) who weighed more than 77.5 kilos (12st 4lb.) Nine other operations that will be restricted include surgical treatment for varicose veins, haemorrhoids, trigger finger and hernia. Children with glue ear will not have grommets inserted unless they have educational, behavioural or other problems.
BUPA, the private hospital provider, said its medical insurance covered all these treatments. "We would not exclude them on the grounds of their weight or other similar criteria."
For people without insurance cover, a hip replacement would cost £7,000-£8,900 and a knee £8,800-£10,300, a spokeswoman said. The BMA said most orthopaedic consultants already recommend against replacing the hips or knees of many obese patients. But everyone should be looked at individually and there should not be a blanket ban on GPs referring overweight people to consultants.
Dr Keeble said the restrictions on hospital care were unlikely to make big savings. "But when your finances are tight, you have to look at all sorts of things to save money."
The Department of Health was asked if it approved of the East Suffolk guidelines. A spokesman said investment in the NHS had doubled since 1997. "It is the role of primary care trusts to ensure that taxpayers' money is used for maximum clinical effect and to best serve the needs of their local patients. Any actions that trusts take to manage to reduce deficits should not lower the quality of care provided to NHS patients."
