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.

Photo: Getty
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The three avoidable mistakes that Theresa May has made in the Brexit negotiations

She ignored the official Leave campaign, and many Remainers, in pursuing Brexit in the way she has.

We shouldn’t have triggered Article 50 at all before agreeing an exit deal

When John Kerr, the British diplomat who drafted Article 50 wrote it, he believed it would only be used by “a dictatorial regime” that, having had its right to vote on EU decisions suspended “would then, in high dudgeon, want to storm out”.

The process was designed to maximise the leverage of the remaining members of the bloc and disadvantage the departing state. At one stage, it was envisaged that any country not ratifying the Lisbon Treaty would be expelled under the process – Article 50 is not intended to get “the best Brexit deal” or anything like it.

Contrary to Theresa May’s expectation that she would be able to talk to individual member states, Article 50 is designed to ensure that agreement is reached “de vous, chez vous, mais sans vous” – “about you, in your own home, but without you”, as I wrote before the referendum result.

There is absolutely no reason for a departing nation to use Article 50 before agreement has largely been reached. A full member of the European Union obviously has more leverage than one that is two years away from falling out without a deal. There is no reason to trigger Article 50 until you’re good and ready, and the United Kingdom’s negotiating team is clearly very far from either being “good” or “ready”.

As Dominic Cummings, formerly of Vote Leave, said during the campaign: “No one in their right mind would begin a legally defined two-year maximum period to conduct negotiations before they actually knew, roughly speaking, what the process was going to yield…that would be like putting a gun in your mouth and pulling the trigger.”

If we were going to trigger Article 50, we shouldn’t have triggered it when we did

As I wrote before Theresa May triggered Article 50 in March, 2017 is very probably the worst year you could pick to start leaving the European Union. Elections across member states meant the bloc was in a state of flux, and those elections were always going to eat into the time. 

May has got lucky in that the French elections didn’t result in a tricky “co-habitation” between a president of one party and a legislature dominated by another, as Emmanuel Macron won the presidency and a majority for his new party, République en Marche.

It also looks likely that Angela Merkel will clearly win the German elections, meaning that there won’t be a prolonged absence of the German government after the vote in September.

But if the British government was determined to put the gun in its own mouth and pull the trigger, it should have waited until after the German elections to do so.

The government should have made a unilateral offer on the rights of EU citizens living in the United Kingdom right away

The rights of the three million people from the European Union in the United Kingdom were a political sweet spot for Britain. We don’t have the ability to enforce a cut-off date until we leave the European Union, it wouldn’t be right to uproot three million people who have made their lives here, there is no political will to do so – more than 80 per cent of the public and a majority of MPs of all parties want to guarantee the rights of EU citizens – and as a result there is no plausible leverage to be had by suggesting we wouldn’t protect their rights.

If May had, the day she became PM, made a unilateral guarantee and brought forward legislation guaranteeing these rights, it would have bought Britain considerable goodwill – as opposed to the exercise of fictional leverage.

Although Britain’s refusal to accept the EU’s proposal on mutually shared rights has worried many EU citizens, the reality is that, because British public opinion – and the mood among MPs – is so sharply in favour of their right to remain, no one buys that the government won’t do it. So it doesn’t buy any leverage – while an early guarantee in July of last year would have bought Britain credit.

But at least the government hasn’t behaved foolishly about money

Despite the pressure on wages caused by the fall in the value of the pound and the slowdown in growth, the United Kingdom is still a large and growing economy that is perfectly well-placed to buy the access it needs to the single market, provided that it doesn’t throw its toys out of the pram over paying for its pre-agreed liabilities, and continuing to pay for the parts of EU membership Britain wants to retain, such as cross-border policing activity and research.

So there’s that at least.

Stephen Bush is special correspondent at the New Statesman. His daily briefing, Morning Call, provides a quick and essential guide to domestic and global politics.

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