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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Michael Carrick is the “Geordie Pirlo” that England misunderstood

The Manchester United legend’s retirement announcement should leave Three Lions fans wondering what if?

That it came in the months leading up to a World Cup arguably added an exclamation point to the announcement of Michael Carrick’s impending retirement. The Manchester United midfielder, who is expected to take up a coaching role with the club afterwards, will hang up his boots at the end of the season. And United boss Jose Mourinho’s keenness to keep Carrick at Old Trafford in some capacity only serves to emphasise how highly he rates the 36-year-old.

But Carrick’s curtain call in May will be caveated by one striking anomaly on an otherwise imperious CV: his international career. Although at club level Carrick has excelled – winning every top tier honour a player based in England possibly can – he looks set to retire with just 34 caps for his country, and just one of those was earned at a major tournament.

This, in part, is down to the quality of competition he has faced. Indeed, much of the conversation around England’s midfield in the early to mid-noughties centred on finding a system that could accommodate both box-to-box dynamos Steven Gerrard and Frank Lampard.

As time went on, however, focus shifted towards trequartistas, advanced playmakers and those with more mobile, harrying playing styles. And the likes of Jack Wilshere, Ross Barkley, Jordan Henderson and Dele Alli were brought into the frame more frequently than Carrick, whose deep-lying capabilities were not utilised to their full potential. That nearly 65 per cent of Carrick’s England caps have come in friendlies shows how undervalued he was. 

In fairness, Carrick does not embody similar characteristics to many of his England midfield contemporaries, including a laudable lack of ego. He is not blessed with lung-busting pace, nor is he enough of a ball-winner to shield a back four solo. Yet his passing and distribution satisfy world-class criteria, with a range only matched, as far as England internationals go, by his former United team-mate Paul Scholes, who was also misused when playing for his country.

Rather, the player Carrick resembles most isn’t English at all; it’s Andrea Pirlo, minus the free-kicks. When comparisons between the mild-mannered Geordie and Italian football’s coolest customer first emerged, they were dismissed in some quarters as hyperbole. Yet watching Carrick confirm his retirement plans this week, perfectly bearded and reflecting on a trophy-laden 12-year spell at one of world football’s grandest institutions, the parallels have become harder to deny.

Michael Carrick at a press event ahead of Manchester United's Champions League game this week. Photo: Getty.

Where other players would have been shown the door much sooner, both Pirlo and Carrick’s efficient style of play – built on patience, possession and precision – gifted them twilights as impressive as many others’ peaks. That at 36, Carrick is still playing for a team in the top two of the top division in English football, rather than in lower-league or moneyed foreign obscurity, speaks volumes. At the same age, Pirlo started for Juventus in the Champions League final of 2015.

It is ill health, not a decline in ability, which is finally bringing Carrick’s career to a close. After saying he “felt strange” during the second-half of United’s 4-1 win over Burton Albion earlier this season, he had a cardiac ablation procedure to treat an irregular heart rhythm. He has since been limited to just three more appearances this term, of which United won two. 

And just how key to United’s success Carrick has been since his £18m signing from Tottenham in 2006 cannot be overstated. He was United’s sole signing that summer, yielding only modest excitement, and there were some Red Devils fans displeased with then manager Sir Alex Ferguson’s decision to assign Carrick the number 16 jersey previously worn by departed captain Roy Keane. Less than a year later, though, United won their first league title in four years. The following season, United won the league and Champions League double, with Carrick playing 49 times across all competitions.

Failing to regularly deploy Carrick in his favoured role – one that is nominally defensive in its position at the base of midfield, but also creative in providing through-balls to the players ahead – must be considered one of the most criminal oversights of successive England managers’ tenures. Unfortunately, Carrick’s heart condition means that current boss Gareth Southgate is unlikely to be able to make amends this summer.

By pressing space, rather than players, Carrick compensates for his lack of speed by marking passing channels and intercepting. He is forever watching the game around him and his unwillingness to commit passes prematurely and lose possession is as valuable an asset as when he does spot an opening.

Ultimately, while Carrick can have few regrets about his illustrious career, England fans and management alike can have plenty. Via West Ham, Spurs and United, the Wallsend-born émigré has earned his billing as one of the most gifted midfielders of his generation, but he’d never let on.

Rohan Banerjee is a Special Projects Writer at the New Statesman. He co-hosts the No Country For Brown Men podcast.