Dominic Lawson: Smokers, tattoos and barmy NHS priorities

Smokers were six times more likely to suffer from 'hospital-acquired infections' than non-smokers
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The Independent Online

The brother of a good friend of mine recently died of a stroke in hospital. The odd thing was that he had gone there for a minor operation on a slipped disc in his back. He was 68 years old, and had smoked about 70 cigarettes a day throughout his adult life. He was, in other words, hopelessly addicted to nicotine.

On his arrival, he was made to dispose of all his cigarette packets. He was offered no nicotine substitutes, not even a patch. Having entered the hospital in as good a spirit as one can be with acute back pain, he became hugely agitated by the enforced and involuntary cold-turkey treatment.

His family are convinced his fatal stroke was caused by this stress and the sudden absence of a drug on which his mind and body had become dependent. The hospital will be able to claim that a stroke is a "smoking-connected" condition - which in reality means nothing more than the statistical fact that smokers are more likely to suffer strokes than non-smokers. It would be impossible to prove beyond doubt that the hospital had caused his death by refusing to let him smoke - but what is undeniable is that it acted with great cruelty.

For the avoidance of doubt, the hospital in question was not one of the two which yesterday declared that they reserved the right not to accept GP referrals for routine operations on those who refuse to give up smoking for several weeks prior to surgery.

One could more easily understand such an attitude if it applied to patients awaiting, for example, coronary bypass surgery. But the hospital managers at Norfolk Primary Care Trust and Newcastle-under-Lyme PCT admitted that their demands applied chiefly to people awaiting completely unrelated standard procedures such as hip and knee replacements. Oh, did I mention that both PCTs are in debt? Norfolk PCT alone is £50m in the red. When I mentioned that fact to a doctor friend he laughed and said it was obvious that their new policy was just "an excuse" to limit operations and thus reduce their overdraft.

On BBC Radio 4's World At One yesterday, the "Director of Clinical Services" at Norfolk PCT, Dr Rob Colebrook, argued that this was not the overriding motive. He said smokers took longer to recover from operations, and therefore more of the Trust's resources were used up by them.

Well, it's obvious that NHS treatment is subject to rationing - that is inevitable with any good for which consumers are not individually charged; but given that we have such a system, it would seem more humane and also more in accordance with the Hippocratic Oath to treat people according to their clinical needs. Dr Colebrook, however, had come armed to the studio with what might without hyperbole be described as a "killer fact". Smokers, he declared, were six times more likely to suffer from "hospital-acquired infections" than non-smokers.

This is an observation to be savoured; it should be rolled around in the mouth like the bouquet from a fine cigar. What Norfolk PCT's Director of Clinical Services was saying is that he would rather not perform routine life-enhancing operations on smokers, because they are too liable to fall victim to the consequences of his staff's inability to maintain proper standards of hygiene. Or, put more bluntly: stop smoking, and we are less likely to kill you.

This sinister development in NHS custom and practice was predictable, especially after the guidelines set out 11 months ago by the National Institute for Health and Clinical Excellence (Nice), the body invented by this government to take the decisions which Secretaries of State for Health find too politically toxic.

Last November, Nice's chairman, Sir Michael Rawlins, issued NHS doctors with new guidelines which allowed them to refuse treatment to patients if they judge that the condition was in some sense self-inflicted. In an interview at the time, Sir Michael chose to illustrate this with the most acceptable example, saying that those waiting for a liver transplant would have to agree to stop drinking: "Alcoholism rots the liver, and if the patient is going to continue drinking, giving them a liver when there is already a shortage of organs is not a sensible use of resources."

Most of us, I suspect, would share Sir Michael's attitude on the handing out by the NHS of such a scarce resource as a donated liver. But if we are going to start allocating limited NHS funds according to the relative responsibility of members of the public for their own medical condition, then we will get into some very interesting debates. For example, should the NHS fund abortions?

Currently, the taxpayer finds the money for about 500 abortions a day. Each costs the NHS on average about £500 - equivalent to almost £100m a year. That is little more than one-tenth of 1 per cent of the total NHS budget, but it would pay for a great many hip replacements.

After all, it is not as if a pregnant woman is suffering from an illness: it is not a tumour that is growing inside her. I think we can take it, given the general state of sexual awareness, not to mention compulsory sex education in schools, that it would be hard to find a woman in this country who is not aware of the consequences of sexual intercourse without contraception. It is true that contraception can fail - but the failure rate is tiny: about one fifth of 1 per cent with the combined pill, and less than a tenth of 1 per cent with the coil.

Here's another suggestion: people who want to remove a tattoo should not expect the operation to be funded by the state. Last week, Rosie Winterton, the Health Minister, admitted that in 2005 NHS doctors had removed no fewer than 187,063 tattoos. Laser treatment and skin grafts are not cheap; some consultants believe the annual NHS bill for such procedures could be as high as £300m. Please understand that your £300m is not being spent on this treatment just to remove the embarrassing evidence of earlier girlfriends (or boyfriends) from the biceps or shoulder blades of Britain's self-modifying classes. No, it is all being spent to "secure mental-health well-being", according to the NHS.

I'm prepared to accept that the NHS bureaucrats who came up with that explanation really believe what they are saying; but only an organisation which has gone collectively barmy could imagine that a man who wants to excise the proof that he once loved a woman called George is a more fitting beneficiary of its surgical resources than a smoker in agony from a rotting hip.