Content note: this post discusses gatekeeping healthcare, and structural oppressions
Various NHS commissioning groups have decided to cut costs by blocking access to surgery for people deemed to be obese, and smokers. To the terminally naive, this can be considered an intuitive, common-sense solution, which would encourage people to make better healthcare choices. To the rest of us, we know that choice is, for the most part, an illusion, and that such bans to healthcare access affect certain groups disproportionately–coincidentally, the same groups who make for convenient scapegoats.
First, let’s look at who’s more likely to smoke. LGBT people are much more likely to smoke than straights, and less likely to try to quit. People with mental illness are also far more likely to smoke–up to 2 in 5 cigarettes smoked will be by a mentally ill person. And of course, these groups are not mutually exclusive, with LGBT people at a higher risk of mental illness. Also, poor people are more likely to smoke, and deprivation makes it harder to stop.
When it comes to obesity, let’s first have a look at what’s deemed obese: some CCGs are using the BMI of 30 as a cut-off, which is an absolutely terrible idea. BMI is a nonsense statistic, particularly when applied to how calculating fat an individual is. A substantial portion of Olympic athletes, upon returning after their heroes’ welcome and perhaps needing an operation on injuries, would be turned away by the NHS, because their body weight is too “obese” for surgery–among other issues, BMI does not distinguish between muscle and fat. It’s also particularly statistically dodgy when someone is particularly tall or short, so Usain Bolt and Simone Biles should be glad they’re not going to find themselves at the mercy of the NHS.
As well as the muscular and the all-round encouraged under usual circumstances, who else is likely to be considered obese? Certain minority ethnic groups are more likely to have BMIs over 30–in the UK, particularly Black Caribbean, Black African, Bangladeshi, Pakistani, Indian and Irish people. Again, mentally ill people are more likely to be at risk, both as a result of their illness itself, or as a result of medication side effects. And once again, poor people are more likely to be considered obese. People with physical disabilities are also more likely to be obese. Incidentally, one of the surgeries “obese” people are blocked from accessing is hip or knee replacements–exactly how the NHS expects them to exercise to lose weight while unable to move, they have not yet explained.
So, NHS trusts with these policies will be disproportionately picking on groups who have been historically and currently disproportionately picked on and blamed for their own misfortune. It is yet another manifestation of the general state approach to behaviour change, which goes like this:
Step 1: Deprive marginalised people of a basic need
Step 2: ??????
Step 3: BEHAVIOUR CHANGE!
Unsurprisingly, there’s no evidence that this works, but it’s a nice little bedtime story for fascists-in-denial to tell themselves, that people are being refused healthcare because they made poor life choices.
At this point, the terminally naive might pipe up that obese people and smokers are at a greater risk of surgical complications than non-smokers or thin people. Yes. That’s true. However, there are also lots of other groups who are at greater risk of surgical complications. Like the elderly. Or the very young. Or malnutrition. Or even drinking moderate amounts of alcohol. Or being a bit cold around the time of your operation. Think of the billions that could be saved if they stopped operating on moderate drinkers: suddenly, there’d be barely any operations, especially if they also stopped operating on kids!
Of course that would be absurd: another myth in play here is that healthcare needs to be rationed at all. The NHS is in crisis, but this crisis isn’t caused by obese people, or smokers, or immigrants, or striking junior doctors, or whichever scapegoat you want to pick. This crisis has been manufactured by years of butchering the NHS. Hospitals are not given enough money to function, and given unrealistic targets to meet on these shoestring budgets, along with a hefty dose of bloated private sector provider inefficiency. In truth, with adequate money, the NHS could happily accommodate everyone who needed treatment.
Given that the government would be perfectly happy for the NHS to go tits-up so the private sector could further cannibalise it, that’s unlikely to happen–that harm comes to the most marginalised people is simply a welcome bonus.