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Why patients are not like badgers

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Owen Paterson, the Environment Secretary, has got egg on his face. Having spent months arguing the case that our countryside was rife with consumptive badgers spreading disease left, right and centre, it turns out that there aren’t as many of the elusive creatures as he thought. The original estimate of 2,400 badgers in the area of the cull has proved to be rather embarrassing, since the company responsible for performing the cull has only managed to kill 850 - well short of the 70% target required to make the cull effective. Whether it’s the badgers that have moved the goalposts, as Mr Paterson claims, or his department has fudged the figures to make the target easier to hit, the new estimate for badgers in the wild has been revised downwards to 1,450.

Whatever the rights and wrongs of the badger cull, there is an important lesson to be learned - making estimates of what is out there is difficult, and if you set a target based on those estimates things can go horribly wrong. Prevalence estimates of disease have been with us for a long time. They help us to understand the epidemiology of particular diseases, and track changes over time; they are useful for estimating the provision of necessary resources when designing health policy - but what they have not been used for, until now, is to set diagnostic target rates.

I may be mistaken, but it seems to me that when the government set a target diagnosis rate of 65% for dementia, they were doing something quite new in health policy, and setting a dangerous precedent in doing so. Diagnosis rates are reported to be below 50%, but are based on questionable estimates that are 20 years out of date. The latest figures suggest that there are fewer cases of dementia than we thought - but the government shows no sign of revising its figures. The target, inevitably, is linked to proactive policies to find new cases - the hospital CQUIN and the GP DES being the prime examples. The question we need to ask, however, is this: what if the estimates are wrong?

When it comes to badgers, at least we can take comfort in the fact that other woodland creatures are unlikely to be mistaken for a badger and included in the cull to make up the numbers. Unfortunately, patients with dementia don’t walk round with distinctive black and white markings, and there is every possibility that all manner of other cases could be caught up in the net of dementia in the drive to increase diagnosis. From mild cognitive impairment to depression, delirium or just plain natural ageing, overdiagnosis is a very real danger.

If we accept this misuse of prevalence data in the dementia debate, and fail to expose the dangers of setting target diagnosis rates, then we can expect more target-driven initiatives to follow - and overdiagnosis, with all its attendant harms, will rise to new heights.

Dr Martin Brunet is a GP in Guildford and programme director of the Guildford GPVTS. You can tweet him @DocMartin68

Readers' comments (8)

  • How about politician culling?

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  • Anonymous 9.56 your comments are now getting quite tiresome and offensive. Please find a more appropriate forum to vent your unhappiness at your treatment.

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  • Critically important point made here Dr Brunet, and well made too. To imagine a less useful exercise in reporting and subsequent number crunching may be difficult to find. Target = 50% of entirely fictitious number = duhhh!!! Holy smoking biros. I think I will write myself a prescription for a large G&T or maybe a neat Grey Goose. Clinical trial note: - A Grey Goose versus White Lightning double blinded trial using a cohort of >1000 geriatric candidates produced an unequivocal result of zero resultant blindness in Grey Goose consumption as opposed to White Lightning ( statistical confidence > 99%)

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  • Ummm.. sorry, left out the White Lightning incidence of blindness, silly me. It was 4.5 ( loss of sight in one eye gave the surprise non-integer result)

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  • Whether it's Badger culling or the NHS targets, the government simply ignores any evidence it doesn't like. The Independent Scientific Group conducted a decade long, randomized Badger culling trail. Their final, peer reviewed, conclusion was that 'Badger culling cannot meaningfully contribute to the future control of cattle TB in Britain.' (ISG Final Report, June 2007).
    However, the NFU demanded a cull, and they got one, however poor the supporting evidence.
    Perhaps there's something similar going on in the NHS, with Private Equity Companies, large insurance interests and various private providers
    playing the role of the NFU, and demanding the government implement it's various 'reforms,' however deleterious the results and however poor the evidence?

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  • Whether it's Badger culling or the NHS targets, the government simply ignores any evidence it doesn't like.

    Appears to apply to a lot of GPs and the NHS too

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  • Ivan Benett

    We all ignore evidence we don't like, and I think using the word screening for dementia has particularly annoyed GPs who have been trained to use critical appraisal skills. There is no way that screening for dementia meets Wilson &Jungner critea (WHO).
    However, we also ignore the evidence that people with cognitive impairment get ill quicker, are more disturbed by hospital admissions, stay in longer, and are more likely to be discharged to a place other than home.
    Avoiding this scenario involves lots of different agencies, but GPs have a role.
    Firstly we have to accept that we are not recording at least some people with cognitive deficit. Second, if we did identify them we could ask them or careers to highlight deterioration early, when still functioning well, and intervene to prevent deterioration. Often a simple infection. Thirdly, we can do what we can to intervene with risk factors, usually cardiovascular. Treat BP but don't go too low. Avoid poly pharmacy, and bare in mind prognostic benefit vs likely absolute benefit and risk of harm may mean prioritising which drugs to give and which to leave off. Fourthly discussion of remaining years, realistic ambitions, affairs in order etc
    We do have a role, but only as part of a wider effort to keep people well and functioning normally. After all it will be us soon enough

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