A report published by the Royal College of Surgeons has found that nearly one-third of Clinical Commissioning Groups (CCGs) in England and Wales have placed ‘mandatory’ restrictions for surgeries based on BMI levels, and nearly 12 percent of the CCGs require patients to quit smoking before they are referred for routine surgical procedures.

There is also at least one mandatory threshold by almost 34 percent of the CCGs, based on smoking status or BMI level of the patients. Nearly 22 percent (one-fifth) of the commissions are currently dictating mandatory weight baselines on referrals for hip and knee transplants, which is an increase from 2014 when only 13 percent of the commissions were placing the same restrictions.

The report also found that nearly 200 CCGs have referral policies of ‘mandatory restrictions’ which imply a restriction from surgery access, and referral to another public health support programme for weight loss or smoking cessation for a specified time. On the other hand, ‘voluntary restrictions’ only imply encouraging patients to lose weight or quit smoking on their own volition, sometimes with the help of some public health support service recommended by their doctors.

Wales have a mandatory policy of a referral for the patients with BMI over 35, to a weight management programme or/and a voluntary smoking cessation programme. CCGs also impose mandatory thresholds for referral before cosmetic surgeries such as breast reductions.

The report was published as another effort after an open letter, published on April 5, 2016, by the Royal College of Surgeons to the chairs of six Birmingham CCGs, for reconsidering their position on placing thresholds on several surgical procedures such as hip and knee replacements, varicose veins treatment and hernia repair among several others.

The letter highlighted that CCGs in their consultation document had ‘subsequently ignored or cited out of context’ several policies from RCS and Surgical Specialty Associations (SSAs), and falsely ‘presented the policies as if they are supported by clinically-evidenced guidance’.

RCS urged the CCGs to revisit their policies which could potentially affect two million people in the region and affect patients by limiting their treatment options. A spokesperson for the Birmingham, Solihull, and the Black Country CCGs said that they had asked for a comment from the college and other key stakeholders, and now that the college has ‘formally commented’, they are taking into account many of the points raised by the college as a part of ‘feedback received through the engagement process’.

He also said that they would continue to take into account the views of the college as they go through each policy.

The President of Royal College of Surgeons Clare Marx has said that public health programs for assisted weight management and smoking cessation are supported by the college and affected patients should be encouraged to avail their services while they wait for the surgery.

She further added, “However, blanket bans that deny or delay patients’ access to surgery are wrong. NHS’ surgical treatment should be based on clinical guidance and patients should be dealt with on a case by case basis. In some instances, a patient might need surgery in order to help them to do exercise and lose weight.”

The recent report by RCS has also highlighted the unprecedented financial burden on National Health Service (NHS) right now that entailed 2.26 billion pounds deficit by December 2015. Nearly 18 percent of the CCGs also predict a deficit by the end of 2015/2016.

The consultation document by the CCGs also states, “CCGs have limited budgets; these are used to commission healthcare that meets the reasonable requirements of its patients, subject to the CCG staying within the budget it has been allocated. By using these policies, we can prioritize resources using the best evidence about what is clinically effective, to provide the greatest proven health gain for the whole of the CCG’s population.”

Clare Marx said regarding the financial aspect of the situation that though it is difficult to prove that these changes have been made to save money, it is unlikely that the CCGs with financial issue are the ones restricting access to surgery. She termed the potential patients in need of a surgery who are overweight and smoke as ‘soft targets’.

CCGs were set up according to Health and Social Care Act 2012, as NHS organizations, to organize service delivery in England. CCGs are clinically led groups formed by all the general practitioners in their geographical area. This gives the power to GPs to influence their patients’ health through commissioning decisions.

According to the Health Survey for England 2014, 41 percent men and 31 percent women are overweight while 24 percent men and 27 percent women are obese in England. NHS currently classifies a BMI above 25 as overweight and a BMI of 30-39 as obese.