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The National Health Service at 60 banner image
Tuesday 09:00 - 09:45,
1- 29 July 2008
Branwen Jeffeys looks at some of the key dilemmas facing the NHS.
Programme 2
Tuesday 8 July 2008
Listen to this programme in full
Aneurin Bevan meets Sylvia Diggory the the first patient of the newly created NHS.
What responsibilities do patients have to the NHS?
To what degree should patients be held responsible for conditions which are caused by their lifestyles? Should smokers be forced to quit before they are treated for unrelated routine procedures?

When treatment is offered with conditions attached the argument is that the decisions are made on a clinical basis - a hip replacement for an obese person will be less successful - but are these really financial decisions?

Taxpayers who smoke, drink or have a BMI over 30 could argue that they’ve funded the NHS throughout their lives and that they shouldn’t be denied treatment when they need it. Is one of the founding principles of the NHS at risk if treatment becomes conditional on changing our lifestyles? 
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    Have your say
    We apologise for the delay in posting your thoughtful and interesting contributions to the debate. It was caused by severe technical problems.

    What responsibilities do patients have to the NHS?

    Please state clearly if you wish to remain anonymous as your message may be read out on air or published electronically. 

    Hugh Mainprice 
    I neither smoke nor am obese but I am at a loss to understand why no contributor has mentioned that tobacco duty paid by smokers goes a a long way to finance the NHS

    Valerie Richardson
    If overweight patients are denied operations due to alleged risk why are so many gastric band operations offered to, and carried out on, overweight patients irrespective of their lifestyle? This is a major operation with obviously greater risk than a knee operation.

    Michael Brooks, Bedford 
    None of your contributors on air have looked at this from the point of view of the taxpayer. I pay high taxes which are then spent on people who refuse to improve their lifestyle (excepting life-threatening cases). The National Health Service is actually no such thing: it is a National Illness Service, with very little of its resources spent on prevention as opposed to cure.

    Helen Frost ,West Yorkshire
    My mother died from lung cancer 12 months ago. Despite having never smoked in her life, and ours being a non smoking family, we felt that she was always discriminated against because it is usually a smoking related disease. As soon as we said that she had lung cancer the attitude of the health care professionals changed. The thing that wore her down more than anything else was dealing with this inbuilt prejudice and constantly having to reiterate the fact that she had never smoked.We feel like screaming when it is suggested that lung cancer is always smoking related and we feel that those who do not smoke, but still contract the disease,are forgotten.

    Mary Anne O'Brien. Surrey
    There used to be a Health Education Council which provided posters and leaflets on all aspects of health and prevention of illness. They contacted schools and other establishments with information and advice. This was closed down but I think the government should set it up again.

    Rand Hobart, Blackpool
    Whenever I visit my GP (which is relatively rarely), and no matter what my issue is, I'm told it's because I'm overweight, every time it's my GPs opening gambit (and this is several GPs over the years). I'm definitely made to feel that I'm the enemy.

    Paul Harrow
    There are strong links between Alcohol abuse, obesity, eating disorders, and low motivation (Lack of exercise, unemployment), and depression, anxiety disorders and other low level mental disorders. Treat these properly and you will achieve savings in many areas inside and outside the NHS and create a better happier more productive society.

    Hen, SE London
    The NHS should have a responsibility to point out how unhealthy lifestyles effect patients' health. May people do not know or understand the consequences of unhealthy diet, for example, and may reform their ways if given the information in an informative and positive light - thereby improving their health and demands on the NHS.

    Peter West,  London We have NICE to restrict the most expensive medicines that do not offer value for money. Beyond that, if we start to discriminate on lifestyle we could pick on all kinds of groups. HIV for example is completely preventable if you are in control of your sex life though many women in the world are not. Would we let the surgeons stop treating a youth with a knife wound if they found a knife in his pocket too? And on top of this, the smokers and drinkers pay a lot more tax and die without costing us for their long term care and pensions. The simple solution is not to discriminate on lifestyle otherwise there is no end to the discrimination we could invent.

    Eric Coates, Leicester
    A theme throughout the programme has been "give the patients information and help them make the choice" Where's the choice in "loose weight if you want your knee operation"? Stop using weasle words!

     Liz, Reading
    The stressful life of a full-time working Mother makes it hard to find time to exercise and always eat healthily, much as I would love to. However I have worked all my life and luckily never had to use the NHS. Should I need to it would seem extremely unfair that the fact I am overweight will mean I would not be treated. Thinking about this, if it turned out that after a lifetime of paying ‘National Insurance contributions’ I was not insured, surely that would mean I would be entitled to a refund – which would enable me to be treated privately!

    Why is the discussion about symptoms of bad lifestyle and not the cause. Please talk about the causes the over production of harmful food and recreational goods by profit obsessed producers. Marketing does work so control it and production of tempting goods in attractive packaging!

    Martin Holland. Horley, Surrey
    I do not believe that NHS treatment should be rationed according to lifestyle choice. If you smoke or are overweight this should not be used as an excuse to refuse you treatment. After all these are only the current "bad guys". Who judges what criteria are used for refusing treatment in the future? It is a very slippery slope. It is not long ago that left handed people were treatment as "odd". I am glad that you raised the topic of George Best and his treatment. It appears that celebrity status allows you to circumvent all the strictures about to be imposed on the rest of us. I regard the NHS as a service that I have pre-paid thousands of pounds for over the years in my taxes. I will not allow anyone to get in my way to accessing the service if I should need it.

    Eleanor Thorn, Madrid 
    I thought about this a lot when the issue was first raised a while ago. I was almost tempted to go with it. However I've realised it is very wrong. Both my parents are obese. Whilst it is true that to some extent they are responsible for their health as in charge of their lifestyle, I am certain that a good part of the responsibility lies with their GP. I know their GP has not adequately informed them of the health risks, nor how to go about changing their lifestyles and how and why to lose weight. My parents need a radical change, but their GP is not there to help them. He prefers to doll out medication and check blood pressure, and if the medication is working that that in his eyes should suffice. I am very cross about this situation. I think that it would be very wrong to deny overweight people treatment when it is the NHS' own shortcomings that contribute in a large way to the size and health today of my parents and many others.

    Cliff, Co Durham 
    Re today's programme, I'd like to challenge the concept of longevity as an end in itself - the deal seems to be "give up everything you enjoy doing, and we'll guarantee you a longer life - but the chances are you'll spend it with dementia". We're now in the 21st century, and the medical profession should long since have got to grips with the problem of low-quality old age - but it's never mentioned. It's taken for granted that everyone should aspire to living as long as possible, no matter what their state.

    paul, brighton 
    All individuals have their own attitude to 'risk'. No-one else can decide for them whether a 'risk' outweighs a 'benefit'. Saying otherwise is completely bogus. One person may risk their life to be taller, someone else may be happy as a dwarf. Only an individual can decide they are content with the additional risk of smoking or being fat.

    I am a GP who has tried to influence NHS management by being a Health Authority director in the past. Two points: (a) until we admit as a society that we cannot do everything for everybody, we will never confront the bottomless pit of patiebt demand, and keep pace with genuine disease/illness. (b) the responsibility of NHS management is upwards to Ministers, not downwards to patients and their advocates, doctors and nurses. Until this confused prioritisation is reversed, tension and confrontation between medical workers and senior NHS management will divert us from making sensible decisions.

    Carlos, london
    It's completely ridiculous to demonise those who have chosen to consume more food of cigarettes and therefore become ill - because they have payed FAR more tax than non smokers (cigs are 6 quid a packet!)and are entitled to treatment because of that surely ?

    Ruth Hunt Edgbaston 
    I gave up smoking of my own accord in 1977. The consequent weight increase has been subject to a lot of nagging but no sensible guidance. Yes, giving up smoking is a good idea, as is sensible eating, but real guidance should be given, not nagging into the arms of profit motivated organisation the result of which is an even greater gain afterwards. Yes, give much more help, but don't penalise a patient for failing.

    Raymond Walker
    Management is so top heavy that simple repair jobs often go through a monthly committee meeting. The SHA, Healthcare Commisson and PCTs waste enormous amounts on lavish printing in overlarge pt type so that a 4 page document will stretch to 8pp. Peripheries like the PPI and now Links is being set up with another sidelining of £35/60M per annum. Reduce management who only keep introducing new untested schemes to keep themselves employe. The NHS should have evolutionary change over decades, not instant change.

    Name: Helen, Brighton 
    I am tired of hearing people ask what responsibilities patients have to the NHS - what about the responsibility of the NHS to patients? As a long-standing suffered of depression I have simply given up on the NHS for other physical ailments because I cannot get proper treatment. Symptoms are never taken seriously but are constantly dismissed as due to depression until they become so severe that they can no longer be ignored by health professionals. We are constantly told about the importance of early detection of illness, yet mental health service users are effectively excluded from early detection due to outrageous discrimination. Chronic illnesses are sidelined and the only effective parts of the NHS are those associated with A&E or the high-profile government-targeted areas of cancer and heart disease.

    Name: Harry Stottle, Bristol
    The only relevant "rule" is that people should pay any costs they incur. As Sam from London points out, Smokers and drinkers pay huge taxes. In fact, smokers pay more than 6 times the costs they incur. But this is NOT true of drinkers. Their health costs are probably covered, but not the social costs of violence and physical destruction which accompanies the consumption of alcohol in too many cases. But that implies an increase in the price of alcohol NOT restrictions on access to treatments for harm. The same logic should apply to all forms of harm either to self or 3rd parties. Tax the harm causing activity to the full extent of the costs which society incurs and then the issue of rationing and nanny statism melts away.

    Val Peterson - Bristol
    When Iworked in the Health Service in the fifities I recall some consultants saying that if a a patient had been told that they had for example to stop smoking for the sake of their health & they wouldnt then they didnt really think they should have to treat them -although of course they did However although I strongly agree that we should all take responsibility for our behaviour but can see its a very tricky area & where will it end - maybe just being old will be one day be seen as too great a burden on the NHS - in fact some of us think that might already be the case in some hospitals & care homes

    Martin Shaw, Huddersfield
    Can we be absolutely clear: smokers pay £10bn a year in tax and the cost of smoking related illness is £1.8bn. Smokers pay massively over the odds.

    Chris, Birmingham
    Both stopping smoking and losing weight are part of the treatment. Patients who refuse to cooperate with their doctors in this way should be given a lower priority than those who do cooperate.

    Grace , Solihull, West Midlands
    When we are deducted our National Insurance Contributions there is no account taken of whether we are smokers or obese. Therefore, if we have paid we should receive treatment as we need it. The NHS treat people from other countries who have never contributed in any way and we need a level playing field.

    I received crude scare tactics when under NHS assessment for complication to a private treatment, to drive me out.

    paul, brighton
    If the NHS don't want to treat someone for any reason, that is fine. But then they shouldn't take their money - and should repay what they have paid in so far.
    J spires Cambridge
    Turn up for appointments and be in some way clued up about your illness, so doctor's can communicate what's happening effectively. Show some committment to getting well.

    Breda Bower. East London
    I manage a GP Practice. I would never consider a penalty for smokers or drinkers. The greatest waste is caused by people who make an appointment with a GP or Hospital Doctor and they do not keep the appointment. I would charge these people for the time wasted. This greatly affects waiting times for appointments and can be avoided.

    Breda, East London
    I manage a GP Practice.I would never consider a penalty for smokers or drinkers. The greatest waste is caused by people who make an appointment with a GP or Hospital Doctor and they do not keep the appointment. I would charge these people for the time wasted. This greatly affects waiting times for appointments and can be avoided.

    Christine, London 
    As a nurse, I've always believed in prevention as sensible and cost-effective. Now, as European director of the Oxford Health Alliance, formed to prevent the global epidemic of chronic disease by focusing on the 3 risk factors (smoking, poor diet and lack of exercise) which kill more people than AIDS (over 50% of preventable deaths) I believe that society & government need to share responsibility with individuals. It's government that has sold school playing fields and failed to secure healthy eating and exercise in schools; fiscal policies could make healthy foods more affordable than unhealthy ones. Areas where it's unsafe to walk or play outside make execise difficult. a welcome concern about the environment and "saving the planet" needs to be matched by a concern for saving enough people to live in it. That is not happening at the moment.

    Sue Paterson Edinburgh
    I think that smoking cessation or weight reduction should count as treatment and patients be offered these as an overall package sometimes before an unrelated (not immediately life threatening) condition is treated.

    Bill, Manchester
    No one is asked if they can afford to contribute to the taxes and insurances which fund the NHS. Indeed people are paying much more towards the costs if they smoke, or drink alcohol, for instance. To refuse treatment to any one of the people who smoke , or have a BMI over (a purely arbitrary) 30 is to steal their previous contributions.

    SWR Southwest
    Smokers ,Drinkers and the obese need help as much as or possibly more than your healhy/well people.Next they will try and stop people who have accidents from medical treatment as they "Did it to themselves"

    Sam from London Town
    Smokers and drinkers pay huge amounts of tax. They also die younger saving the NHS money as it is the elderly who cost said organisation most. The NHS should pay people to drink and smoke. I do neither.

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