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‘We need to step away from artificial targets' 

As the lead of a new group tasked with examining the harms of overdiagnosis, Dr Margaret McCartney tells Pulse reporter Caroline Price why a wider debate is needed about the direction medicine is heading.

Dr Margaret McCartney is a GP on a mission. Through her insightful contributions in both the medical and lay press over the past decade, she has provided a refreshing alternative voice to the prevailing discourse on some of the biggest controversies in medicine. In particular she has challenged received wisdom about the benefits of health screening programmes, raising concerns about the risks of over-medicalising the population.

As a result she has become somewhat of a champion for a growing body of GPs across the UK who are increasingly uneasy with what they see as the drive to diagnose and treat patients, without due consideration of the potential harms such policies bring - not only to the individual patient but to the health of the wider public.

Dr McCartney has wasted no time in using her platform on RCGP council to take these concerns right to the top of the agenda. Since her election to council last year, she has instigated the creation of a new standing group, specifically tasked with addressing these problems and giving GPs more support and professional guidance on how to deal with the conundrum in their daily practice.

The creation of the group, she tells Pulse, has come out of growing concerns from GPs that the Government is shifting the focus away from those patients with the greatest need onto preventative measures for healthy people, for which the benefit-to-risk ratio is far less certain.

‘Over the last decade we’ve become more aware that quite often too much medicine is a bad thing, and lots of concerns have been raised that we’re going in the wrong direction with an awful lot of healthcare,’ she says at the group’s official launch at the RCGP annual conference.

‘What [the group] wants to do is.. to try to address the kinds of problems that we see, in terms of policy, practice and patients,’ she adds.

‘I think there are issues in all those three areas that are going in the wrong direction now and need to be hauled back, taken within professional control, working in partnership with patients, making sure we’re getting appropriate care to the people who need it and will benefit from it, while – in the main – leaving most well people alone.’

The group will focus on giving GPs more of a say in how policies and guidelines are developed – as well as giving them the tools to deal with the complexity of their daily practice. They plan to produce two pieces of work over the course of the next eighteen months to two years.

She says: ‘We’re interested in policies that drive over-diagnosis and under-diagnosis – in particular thinking about prescribing practices, guidelines and QOF and what could be done to try and help in those areas.

‘We’re also thinking about practice day-to-day. How to make good evidence-based decisions with patients in the stress of a 10-minute consultation – and quite often two or three problems from patients. So, what kind of information we need easily on hand within five seconds, to help GPs and patients make good decisions.’

But Dr McCartney is also clear these problems are part of a wider debate to be had with patients and in society in general, about the direction of medicine and how best to use limited healthcare resources.

She says: ‘I think it’s patients who deserve to know that the resources are not going in the right direction at the moment and that we should be redirecting it to people who are most likely to benefit.’

She says recent controversy surrounding NICE lowering the primary prevention risk threshold for interventions – including use of statins - to prevent cardiovascular disease feed directly into this debate.

She says: ‘In a limited system, who are we to stop doing in order to make space for doing risk assessments on all these millions more people? It is fine for NICE to do cost-effectiveness evaluations, but are these the only thing that should count – are there other issues involved? I think there are.

‘I think it is good to have a wider public debate about this – what direction medicine is going, what we expect of the NHS, what it can provides for us and where we want to draw the line.’

Similarly, Dr McCartney argues the controversy over policies to incentivise GPs to screen for and diagnose dementia marks a watershed – a time to ‘let go’ of targets and let GPs’ professionalism take precedence.

She says: ‘There is a revolution needed, we need to step away from targets… that create deprofessionalisation of our work, and let go.’

She adds: ‘Doctors are vocationally trained, reflective people paying attention to the evidence… peer review, being open about diagnosis rates, alert to criticism – that should be what we are basing our practice on. It should not be the creation of artificial targets.’

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Readers' comments (6)

  • Did NH Stevens discuss this issue at all in his 5 year plan? No because it is a service led by bunch with little or no interest in patients or those people who are supposed to look after them.

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  • Vinci Ho

    There is a revolution needed ....against whom?
    Revolution against NHSE, DoH and politicians.
    Although , 1984 was my favourite , George, the ending was very disappointing.
    On the same tone of dystopia, much prefer the finishing of Hunger Games, look forward to the film coming this month.......

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  • Absurd, non mathematical targets are everywhere. Here is one - A+E depts are failing to meet 4 hour targets.
    4 hours to see how many people ? 100? 1000? We have these one sided equations like 4 hour targets, 6 week waiting, 2 week referral etc without any idea of input numbers.
    We have these absurd absurd targets made up by managers who have no arithmetic whatsoever. Most of them have done Spanish or something like that.

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  • Reading your book *the Patient Paradox*....keep up the good fight...

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  • Getting rid of QOF might be a good start

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  • NHS Scotland had a financially incentivised approach to the "early diagnosis" of dementia. This was HEAT Target 4. The target was reached and the Scottish Government were triumphant about this presenting the achievement to Westminster in 2012 (All Party Parliamentary Group)

    NHS Board in Scotland took robust measures to reach the target and thus gain the financial reward. Practice became skewed in many ways to reach the target.

    This target was set by the Scottish Government. The most Senior Official for Mental Health in the Government (Mr Geoff Huggins) stated that the Government had been careful "to take out saboteurs" and that any disagreement by doctors or managers would be dealt with "behind the bike shed".

    Wind on nearly 4 years and it is emerging that elderly patients were mis-diagnosed with "early dementia" as a result of this target. In fact they have static age-related memory loss and not dementia.

    Scotland stands as evidence emerges of the harmful effects of an incentivised target based on "early diagnosis". It is no light matter to make a wrong diagnosis. Ask those mis-diagnosed.

    I personally campaigned across the United Kingdomfor an approach based on a TIMELY approach to diagnosis. This approach was completely rejected by the Scottish Government throughout my "engagement" with them. But CURIOUSLY the Scottish Government are now taking credit for a timely approach to diagnosis. This is quite sickening as Scotland could have offered an important lesson had the Scottish Government been open, honest and shown probity.

    I agree with all those who say that chasing a crude uncertain population target, a target that is politically motivated and has been promoted RELENTLESSLY by the Alzheimer's Society is UNETHICAL.

    This approach risks generating a huge amount of fear. It also risks medicalising too much of ageing such that those living with dementia are further disadvantaged as services get ever more stretched.

    Above all a TARGET like this, an I realise that NHS England call it an “ambition”, ignores complexity and the parabolic distribution of cognition over our life course. Our elder generation deserve far far better.

    Dr Peter J. Gordon
    Psychiatrist for Older Adults
    NHS Scotland

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