Redefining disease could save millions, says Copperfield, so why haven't we done it yet?
Just for a change, I'm starting this week's column with a picture: Magritte's Treachery of Images. You know, the one that's a picture of a pipe with the caption: ‘This is not a pipe.' It hangs on my surgery wall, to confuse the punters and give me a slight superiority complex (‘Ah, but you see, it's not a pipe, is it, it's a picture of something we call a pipe. Anyway, here's some more Nicorette, now bugger off.')
Hold onto that image. Now shift your focus to a summary I'm holding of the 178-page local QIPP strategy. Listen to this.
It says, in the QIPP plan for mental health, bullet point five: ‘Reduction in number of people with neurotic conditions.'
OMG: they're asking us to do a cull. No wonder these patients are anxious.
Hang on, though. I suspect those QIPPsters probably just mean that we should toughen up on soft psychiatric labels. Generalised anxiety disorder is simply being a worrier. OCD is just being careful. And no, you don't have Velcro phobia, it terrifies everyone. Brilliant.
‘This is not a neurosis' – instantly, masses of money saved on drugs and CBT appointments.
This policy also redresses an imbalance. Traditionally, surgical specialties have borne the brunt of service restrictions – stretched budgets lead to recalibrations of the populace's need to have hernias repaired, hips replaced and so on. But the medical specialities can do their bit, too – simply by replacing pathological labels with a pat on the head. COPD becomes smoker's cough, dementia forgetfulness and stroke age-related unlilateral weakness.
Primary cardiovascular prevention is another area of potential savings. We'd just have to incorporate the extra step of ‘take away the first number you thought of' into our risk calculations. What about terminal care? The emphasis would change from the unnecessarily interventionist ‘end-of-life care' to a more positive and forward-looking ‘pre-death pathway', with minimal input from health professionals – at least until the crem papers need signing.
Perhaps most dramatically, the prevalence of diabetes and hypertension could be slashed, simply by resetting the diagnostic thresholds. Someone clever would need to do some proper number-crunching, but, off the top of my head, I'd suggest ‘20mmol/L' and ‘200/100' – they're easy to remember. True, this could bump up cardiovascular mortality, but there are always going to be winners and losers in any health service shake-up. Besides, some of the victims would probably have been neurotic, anyway (see QIPP bullet point five).
It's all so obvious, you wonder why nobody's thought of it already. Except they probably have. After all, we're being pushed, almost without protest, into a world where we're rewarded for cutting prescribing, referrals and admissions. It's only a short conceptual hop to agreeing that the definition of disease itself is more about political imperatives than science.
In the meantime, I'll paint my own picture: of a man with a stethoscope and a perplexed expression. It'll have the caption: ‘This is not a job.'
Dr Tony Copperfield is a GP in Essex
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