...in the old days, I decided who was "fit" for referral and duly referred. If the specialist did not agree, he would say so. Now, there is a commissar between me and the specailist, and the commissar, who is not medically qualified, tells us both how to do our job.

This protocol is not about economics. It is about blame. It is “your fault” you are fat. Fat people are stupid. Fat people are probably mentally ill. So we are not going to waste money on them unless they are penitent. Unless they admit the error of their ways and promise to behave. Unless they can demonstrate that they “deserve” treatment.

This protocol is about humiliation. Humiliating the patients by making them jump through hoops and humiliating the doctors by telling them how to do their jobs.