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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David Blunkett compares Labour membership to failed revolution “from Ukraine to Egypt”

The Labour peer and former home secretary says new members need a “meaningful political education”, and accuses unions of neglecting their “historic balance”.

There are three sorts of opposition. There’s the civil society opposition, with people campaigning in their own specific areas, people who’ve got an interest group or are delivering social enterprise or a charity. I don’t think we should underestimate that because we're going to have to hang on to it as part of the renewal of civil society.

The second is the opposition formally, within the House of Commons: those who have agreed to serve as the formal shadow ministerial teams. Because of what I’d describe as the turmoil over the last two years, they’ve either not been able to be impressive – ie. they’re trying very hard but they don't have the coherent leadership or backing to do it – or they’ve got completely different interests to what it is they’re supposed to be doing, and therefore they’re not engaged with the main task.

Then there’s the third, which is the informal opposition – Labour linked sometimes to the Lib Dems and the SNP in Parliament on the opposition benches as a whole. They’re not doing a bad job with the informal opposition. People getting on with their work on select committees, the departmental committees beginning to shape policy that they can hopefully feed to the National Executive Committee, depending on the make-up of the National Executive Committee following this year’s conference. That embryo development of coherent policy thinking will be the seed-bed for the future.

I lived through, worked through, and was integrally involved with, what happened in the early Eighties, so I know it well. And people were in despair after the ‘83 election. Although it took us a long time to pull round, we did. It’s one reason why so many people, quite rightly in my view, don't want to repeat the split of 1931 or the split of 1981.

So they are endeavouring to stay in to argue to have some vision of a better tomorrow, and to persuade those of goodwill who have joined the party – who genuinely believe in a social movement and in extra-parliamentary non-violent activity, which I respect entirely – to persuade them that they’ll only be effective if they can link up with a functioning political process at national level, and at townhall and county level as well.

In other words, to learn the lessons of what’s happened across the world recently as well as in the past, from the Ukraine to Egypt, that if the groundswell doesn’t connect to a functioning party leadership, then, with the best will in the world, it’s not going to achieve its overall goals.

How do we engage with meaningful political education within the broader Labour party and trade union movement, with the substantially increased rank-and-file membership, without being patronising – and without setting up an alternative to Momentum, which would allow Momentum to justify its existence as a party within a party?

That's the challenge of the next two years. It's not just about someone with a vision, who’s charismatic, has leadership qualities, coming forward, that in itself won’t resolve the challenge because this isn't primarily, exclusively about Jeremy Corbyn. This is about the project being entirely on the wrong trajectory.

A lot depends on what the trade unions do. They command effectively the majority on the National Executive Committee. They command the key votes at party conference. And they command the message and resources that go out on the policy or programmes. It’s not just down to personality and who wins the General Secretary of Unite; it’s what the other unions are doing to actually provide their historic balance, because they always have – until now – provided a ballast, foundation, for the Labour party, through thick and thin. And over the last two years, that historic role has diminished considerably, and they seem to just be drifting.

I don’t think anybody should expect there to be a party leadership challenge any time soon. It may be that Jeremy Corbyn might be persuaded at some point to stand down. I was against the challenge against him last year anyway, purely because there wasn't a prepared candidate, there wasn't a policy platform, and there hadn’t been a recruitment drive to back it up.

People shouldn’t expect there to be some sort of white charger out there who will bring an immediate and quick end to the pain we’re going through. I think it’s going to be a readjustment, with people coming to conclusions in the next two years that might lead the party to be in a position to fight a credible general election in 2020. I’ve every intention of laying down some good red wine and still being alive to drink it when the Labour party is elected back to power.

David Blunkett is a Labour peer and former home secretary and education secretary.

As told to Anoosh Chakelian.

This article first appeared in the 30 March 2017 issue of the New Statesman, Wanted: an opposition