“Thank you for waiting, Mr Collins. We have now completed all our tests and are very pleased to let you know that they are completely normal. You can now be discharged.”
Mr Collins’ face falls. “But I’ve still got the symptoms,” he says. “I’m no better than when I came to see you three months ago and you did all these tests.”
“I quite appreciate that, Mr Collins,” the doctor replies. “But there is nothing more that cardiology/respiratory medicine/endocrinology/gastroenterology/neurology can do for you. Perhaps it might be related to stress. Goodbye.”
This conversation, or variations of it, crops up hundreds of times a day in hospitals up and down the country. Each one of these “consultant episodes”, as they are called in official statistics, costs an average of £600, takes up valuable out-patient or A&E time unnecessarily, and clogs up an already over-worked system. As many as one in five of all consultations in hospitals come into this category.
So what is going on here and why is nothing being done about it? The condition Mr Collins has is called health anxiety, a somewhat modified term that overlaps with the older one of hypochrondriasis, a condition long thought to be untreatable. People with health anxiety worry excessively about their health and one of their main tasks in life is to monitor it constantly.
When they get symptoms such as chest pain, breathlessness, muscle twitching, headache and the many other symptoms that to most others are regarded as fairly trivial, they fear they may have a serious illness. So chest pain equates to a heart attack, breathlessness to lung cancer, muscle twitching to motor neurone disease, and headache to brain tumours. The patient’s personal health monitor moves into overdrive and an appointment is made with the doctor or, if regarded as an emergency, leads to a 999 call or a trip to the A&E department.
All the evidence suggests this condition is becoming more common; it is being reinforced by searching symptoms online. You have to wait for a medical appointment, but the internet doctor is available around the clock. It knows everything and nothing – you get a full list of all the underlying causes of symptoms, but precious little about their likelihood. And the health-anxious patient is inexorably drawn to the description of the least common but most serious conditions, and this only reinforces their anxieties. The internet version of health anxiety is now known as “cyberchondria”.
About one in 16 people suffer from health anxiety, and most of those with the condition have had it for several years. So why is nothing apparently being done about this silent epidemic that represents a major source of suffering and a drain on resources in the NHS?
There are three clear reasons:
The first is that most people with health anxiety do not think they have a disorder and so defend their health-seeking behaviour, often tenaciously, and make appointment after appointment with as many doctors who are prepared to listen to them.
The second is that most doctors in general hospitals are not trained to recognise health anxiety, only to diagnose or exclude conditions within their speciality, and do not realise that there are successful psychological treatments available for the condition that are so much better than the standard reassurance currently being meted out. Nurses in general hospitals have been shown to be highly effective therapists for health anxiety and can be readily trained.
The third is the perverse incentive of what is called “payment by results” – the system by which hospital trusts are paid by the number of people they see and the assessments and interventions associated with their care. It is not really payment by results, merely payment by activity, even if the activity is pointless.
This paradoxically leads to people with health anxiety being more likely to be over-investigated, as each test brings in extra cash, even though most are largely unnecessary. In our own experience, we have encountered this in suggesting at one trust that a new service be set up for people with health anxiety. A business case was prepared but we very quickly had a response, along the lines of: “This is a no-brainer. If we introduce this service we will lose money. Please go away.”
So what can be done now? In the NHS five-year plan accepted by all political parties before the election, chair of NHS England Simon Stevens gave special attention to initiatives to improve mental health and made this plea: “Over the next five years, the NHS must drive towards an equal response to mental and physical health, and towards the two being treated together.”
Yes indeed it must, but even if implemented, this would not improve the care of those with health anxiety unless we can increase recognition of the condition by all staff in general hospitals, provide a proper cost-effective service for the condition, and get rid of the perverse funding incentive.
When Andy Burnham visited us at the Royal College of Psychiatrists before the election to promote “parity of esteem” for mental health, I asked him about this unintended consequence of payment by results, as this was introduced by the Labour government ten years ago. He agreed it needed major reform as it was no longer fit for purpose. Let us hope the present government can also see the light.
Peter Tyrer is a doctor.