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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Commons Confidential: Smith, selfies and pushy sons

All the best gossip from party conference, including why Dennis Skinner is now the MP for Selfie Central.

Owen Smith discovered the hard way at the Labour party conference in Liverpool that one moment you’re a contender and the next you’re a nobody. The party booked a luxurious suite at the plush Pullman Hotel for Candidate Smith before the leadership result. He was required to return the key card the day after Jeremy Corbyn’s second coming. On the upside, Smith no longer had to watch his defeat replayed endlessly on the apartment’s giant  flat-screen TV.

The Labour back-room boffin Patrick Heneghan, the party’s executive director of elections, had good cause to be startled when a TV crew pounced on him to demand an interview. The human submarine rarely surfaces in public and anonymity is his calling card. It turns out that the bespectacled Heneghan was mistaken for Owen Smith – a risky likeness when vengeful Corbynistas are on rampage. There’s no evidence of Smith being mistaken for Heneghan, though. Yet.

Members of Labour’s governing National Executive Committee are discovering new passions to pass the time during interminable meetings, as the Mods and the Corbs battle over each line of every decision. The shadow cabinet attack dog Jon “Sparkle” Ashworth, son of a casino croupier and a bunny girl, whiles away the hours by reading the poetry of Walt Whitman and W B Yeats on his iPad. Sparkle has learned that, to echo Whitman, to be with those he likes is enough.

I discovered Theresa May’s bit of rough – the grizzled Tory chairman, Patrick McLoughlin, a former Derbyshire coal miner – does his gardening in steel-toecapped wellies stamped “NCB” from his time down the pit thirty years ago. He’ll need his industrial footwear in Birmingham to kick around Tories revolting over grammar schools and Brexit.

Another ex-miner, Dennis Skinner, was the MP for Selfie Central in Liverpool, where a snap with the Beast of Bolsover was a popular memento. Alas, no cameras captured him in the Commons library demonstrating the contorted technique of speed-walkers. His father once inquired, “Why tha’ waddling tha’ bloody arse?” in Skinner’s younger days, when he’d top 7mph. Observers didn’t dare.

The Northern Poorhouse minister Andrew Percy moans that he’s been allocated a broom cupboard masquerading as an office in the old part of parliament. My snout claims that Precious Percy grumbled: “It’s so small, my human rights are violated.” Funny how the only “rights” many Tories shout about are their own.

The son of a very prominent Labour figure was caught trying to smuggle friends without passes into the secure conference zone in Liverpool. “Don’t you know who I am?” The cop didn’t, but he does now.

Kevin Maguire is the associate editor (politics) of the Daily Mirror

Kevin Maguire is Associate Editor (Politics) on the Daily Mirror and author of our Commons Confidential column on the high politics and low life in Westminster. An award-winning journalist, he is in frequent demand on television and radio and co-authored a book on great parliamentary scandals. He was formerly Chief Reporter on the Guardian and Labour Correspondent on the Daily Telegraph.

This article first appeared in the 29 September 2016 issue of the New Statesman, May’s new Tories