Targeting Health Care Funding

Health care is a limited resource and most accept that some form of rationing is necessary, but the question is, both how should health care be rationed and how will rationing be sold to the public?

Age has long been used as a criterion for refusing treatment (Rivelin 1995) with both overt and covert ageist policies within the NHS (Sims 1993).  A GPs survey found many were aware of services restricted by age including heart bypass surgery, knee replacements and kidney dialysis (Age Concern 2000).  Whilst most cancers occur in people over 65, there is mounting evidence that this group of patients are receiving less treatment and that this inequitable access to cancer care is resulting in poorer outcomes (Lawler 2014).

From the literature it is unclear what the drivers of reduced care are; restricting demand to save resource or older patients may benefit less from treatment because of co-morbidity?

An alternative approach would be to encourage individuals to take more responsibility for their own health and their life style choices to reduce health demands:  Would this be feasible, how would it be enforced and would it improve access to healthcare?

To help reduce a £14.5 million deficit, the NHS in Devon has introduced new rules for routine surgery: people who smoke will have to quit eight weeks before any kind of routine surgery, whilst people with a BMI over 35, must lose 5% of their weight (

The association between smoking and postoperative complications is well documented across surgical specialities.

A 2010 Cochrane review of preoperative interventions for smoking cessation found that stopping smoking four to eight weeks before surgery may reduce the risk of:


  • wound-related complications
  • lung and heart complications
  • Prolonged stay in hospital after surgery. People who smoke remain longer in hospital – increase hospital costs and reduce availability of services  to treat other patients

(Thomsen T et al 2010)


Approximately 50% of obese patients have a poor outcome following joint replacement surgery compared to less than 10% of patients with a healthy body mass index (BMI). Reasons include:


  • A significantly higher risk of a range of short-term complications
  • A less certainty of surgery improving symptoms
  • A higher incidence of weight gain following joint replacement surgery.

(Dowsey et al 2009)


Complications, associated with pre-operative risk factors, cost the overstretched NHS additional resources and it could be argued that individuals have responsibilities to the NHS and society, in reducing their burden on services.

However, introducing this concept can be argued as rationing and eroding the core principles of the NHS.

Is this rationing?  Or is it optimising limited resources and ensuring everyone gets a fair share of the NHS?  What other areas could be included in the future?

How will politicians sell these concepts of sharing resources better, not by rationing, but restricting certain lifestyle groups to have access to a larger slice of the small NHS cake?

The NHS in its current format is not sustainable. Perhaps the time is right for an honest and transparent debate about the way forward.



Age Concern 2000, New Survey of GP’s confirms ageism in the NHS, ACE.

Dowsey M, Lieu D, Stoney J, Choong P (2009) The impact of pre-operative obesity on weight change and outcome in total knee replacement. J Bone Joint Surg [Br]2010;92-B:513-20.


Lawler, M, Selby P, Aapro M, Duffy S (2014) Ageism in Cancer Care BMJ;348:g1614

Rivelin, M. 1995, “Protecting Elderly People: Flaws in ageist arguments”, British Medical Journal, vol. 310, pp. 1179-1182.

Sims, J. 1993, “Rationing comes in by stealth”, Healthcare Management, vol. 1, pp. 23-26.

Thomsen T, Villebro N, Møller AM.(2010)  Interventions for preoperative smoking cessation. Cochrane Database of Systematic Reviews Issue 7.


Helen Behrens is a registered nurse, and health and social care trainer, who believes training provides an opportunity to improve care and practice for vulnerable people by challenging prejudice and stigma, enabling people to reflect upon one’s own practice and update knowledge and skills.

December 10, 2014 Helen

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