The UK doesn't provide enough medical care for some – and too much for others

Doctors and patients need to question unnecessary procedures, writes Dr Margaret McCartney.

Earlier this year, I was in Washington listening to the reasons why the "Choosing Wisely" campaign was set up. This is the country which spends the most per head on healthcare in the world. The doctor on the podium was not happy. We are doing too many tests, too many procedures, and prescribing too many medicines, he said. Doctors needed to wisen up and stop doing do much stuff. “Basically; what we're saying is; don’t be stupid.”

Choosing Wisely is a campaign backed by the full force of the American medical hierarchy – from the American College of Surgeons to the Society of Critical Care Medicine. Each learned institution has come up with “Five Things Physicians and Patients Should Question.” So the American Academy of Paediatrics says that CT scans for minor head injuries aren’t necessary (when, currently, 50 per cent of children attending in these circumstances are being sent to the CT scanner.) The College of Physicians says that you shouldn’t do X-rays in straightforward low back pain. Elsewhere: don’t use high dose antacid drugs when you can use them at low dose – or not at all. Don’t use feeding tubes for people with dementia – concentrate on helping the person feed by mouth. They are pledges to do better medicine, but also, crucially, to do fewer tests and procedures, and prescribe fewer pills. And to be "less stupid" - stop doing things that the evidence tells us doesn’t work.

This is a volte-face for American doctors. But it's also a contrast to the UK, where the more-is-more philosophy has been gathering pace amongst medics. The contract which GPs work to is in many cases a payment per intervention: We check blood pressures and cholesterols because when patients come in to see us, there are small boxes on the computer screen which tell us they are due (we are paid when we hit the target); campaigns from the Department of Health urge us to achieve more ‘early” diagnosis; health secretary Jeremy Hunt has been vocal in criticising GPs for not diagnosing dementia as often as we apparently should.

The message is that faster diagnosis and more medicine is better. The US still advocates multiple non-evidence-based interventions, in vastly greater quantity than the UK: for example, breast and internal examinations are routine for a straightforward prescription of the contraceptive pill.

Even so, we still have an awful lot of treatment of conditions that would never have brought the patient to any harm. For example, for a patient who has never had a heart attack or stroke, treating cholesterol with statins for 5 years will stop 1.6 per cent of people having a heart attack, and 0.4 per cent from having a stroke. This means that the other 98 per cent get no benefit – but they still get the harms. The risk of developing diabetes caused by the statins is 1.5 per cent. And the cost of overtreatment is not just financial cost, or side effects, but also of making perfectly healthy citizens into patients.

Now the US is keen to talk about doing less. Quite right: it is unsustainable to spend as much as they do on tests, procedures or medications and afford it. But the twin of cost is effectiveness; using less unnecessary medicine saves money, but also reduces harm. During the last US election, when some US commentators accused the National Institute of Clinical Excellence’s judgements as being that of a “death panel” they failed to see the point: not all medicine is good for us. Some of it is decidedly bad for us. Some of it simply doesn’t work.

Jeremy Hunt’s idea of "early diagnosis" for dementia is a case in point. He wants people who have concerns about their memory to be rapidly assessed for dementia. The problem is that most people will have experienced problems with their memory, and the vast majority do not have dementia. Many memory problems in older people can be low grade and not particularly medically concerning. Known as MCI, moderate cognitive impairment, it progresses to dementia in only a minority of cases. But because the psychological testing and the brain scans are not highly specific for dementia, it means false positives are common – some people will be told they have dementia when they don’t.

Meantime, the people who really do have problems with not just memory but their ability to function because of it are less likely to see their doctor to discuss it – and more likely to have a serious underlying cause. The paradox is that the most healthy get tests they don’t need, and diagnoses they don’t benefit from, while the most ill get least care – as usual.

This is the real crunch, and the prize. The Inverse Care Law – that most healthcare goes to the people who benefit least from it – was described by GP Julian Tudor Hart in 1971. We have progressed very little with reversing it. Perhaps we can, now. More and more of the medical establishment can see that we have a problem: too much medicine for some, but not enough medical care for others. Facing up to the stupidly of the current status quo is a start.

Photograph: Getty Images

Margaret McCartney is a GP in Glasgow who broadcasts for Radio 4's Inside Health and is author of The Patient Paradox: Why Sexed-Up Medicine is Bad for Your Health.

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Jeremy Corbyn's speech on terrorism will do him more good than harm

The Labour leader's criticism of police cuts and western foreign policy will resonate with voters.

The election campaign, if there was any doubt, has resumed. In his speech responding to the Manchester attack, Jeremy Corbyn did not limit himself to expressions of sympathy and solidarity. He squarely targeted Theresa May on her home turf: policing and security.

The Conservatives' repeated warning is that Corbyn is a "threat" to his country. But the Labour leader countered that only he could keep it "safe". Austerity, he declared, "has to stop at the A&E ward and at the police station door. We cannot be protected and cared for on the cheap." May, having been warned by the Police Federation while home secretary of the danger of cuts, is undoubtedly vulnerable on this front. Under Labour, Corbyn vowed, "there will be more police on the streets" (despite Diane Abbott's erroneous arithmetic), while the security services would receive whatever resources they need.

Corbyn swiftly progressed to foreign policy, the great passion of his political life. Though it is facile to reduce terrorism to a "blowback" against western interventionism (as if jihadists were Pavlovian dogs, rather than moral agents), it is blinkered to dismiss any connection. As Corbyn noted: "Many experts, including professionals in our intelligence and security services have pointed to the connections between wars our government has supported or fought in other countries, such as Libya, and terrorism here at home" (the Tory-led Foreign Affairs Select Committee is among those who agree).That the former Stop the War chair has long taken this view absolves him of the charge of crude political opportunism.

Corbyn was also more careful than his pre-briefed remarks suggested to caveat his criticisms. He emphasised: "Those causes certainly cannot be reduced to foreign policy decisions alone. Over the past fifteen years or so, a sub-culture of often suicidal violence has developed amongst a tiny minority of, mainly young, men, falsely drawing authority from Islamic beliefs and often nurtured in a prison system in urgent need of resources and reform.

"And no rationale based on the actions of any government can remotely excuse, or even adequately explain, outrages like this week’s massacre."

But he maintained his central charge: western intervention has made the world more dangerous, not less. "We must be brave enough to admit the war on terror is simply not working," he said. "We need a smarter way to reduce the threat from countries that nurture terrorists and generate terrorism."

Though Corbyn's arguments have appalled Conservatives (and some in Labour), they are ones that will likely find favour among the public. Polls have consistently shown that most voters oppose western adventurism and believe it has endangered the UK. Corbyn's words will resonate among both the anti-interventionist left and the isolationist right (this is, after all, a country which has just voted to retreat from even its closest neighbours).

The speech, given at 1 Great George Street (in the room where Ed Miliband gave his resignation address), was marred by Corbyn's refusal to take questions. But it was unarguably well-delivered. "Let’s have our arguments without impugning anyone’s patriotism and without diluting the unity with which we stand against terror," he warned in a pre-emptive strike against the Conservatives.

Corbyn's decision to give an overtly political speech four days after the Manchester attack is being widely described as a "gamble" or even a profound error. But the election will now rightly focus more closely on the issue of security - nothing should be beyond democratic debate.

Many of Corbyn's life-long stances, such as unilateral disarmament, do not find favour with the electorate. But there was little in his speech today that the average voter would contest. The Conservatives will hope to turn the heightened security debate to their advantage, ruthlessly quoting Corbyn against himself. But on this front, as on others, the Labour leader is proving a tougher opponent than they anticipated.

George Eaton is political editor of the New Statesman.

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