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Problem solved in the blink of an I


It has just occurred to me that the ongoing and massive problems afflicting our glorious NHS actually boil down to just one letter of the alphabet.

To explain: on looking through our appointments for January 2020, I noticed two things. One, there aren’t any. And, two, that’s because all the slots are taken up by the following: health checks, medication reviews, learning disability medicals, mental health reviews, rheumatoid reviews, dementia annual reviews, multimorbidity reviews, BP checks, diabetes checks, COPD checks, asthma checks, annual checks to check that patients are getting all their checks, and so on.

So there it is. We’re constantly and compulsively checking patients: the OCDr will see you now. All these reviews and medicals mean 90% of our work is labour-intensive, low-yield, box-ticking claptrap imposed via diktat from NICE/QOF/CQC/DES/LES et al.

And all this mind-numbing labour seems to achieve is more work. To give just one example: that health check inevitably generates a borderline BP, resulting in 24-hour ambulatory monitoring, associated bloods and ECG, initiation of treatment, follow-up appointments and further monitoring. About 10 appointments just to get the patient stabilised on treatment, not counting calls and visits to address anxieties, misconceptions and side-effects. Then a lifelong cycle of call, recall, monitoring and, yes, checks. Last time I looked, the NNT to prevent one death from hypertension was around 100, and that’s if patients take their meds, which they don’t.

Besides, that ‘one’ in the NNT: he doesn’t live forever. If a CV event doesn’t get him, then CKD, cancer, dementia or whatever will. So I’m not sure what we’re saving him from, except, perhaps, a swifter, cleaner exit, although here the health economical and philosophical arguments get a bit murky.

We spend so long trying to keep people healthy we have no capacity to manage the sick

And this is going to get worse, because the Hancock-eyed NHS of the future promises more cancer screening, enhanced CV checks and DNA testing for newborns.

Conclusion? We’re still being peddled that Utopian illusion that prevention is better than cure, that more medicine equals a healthier population. With few exceptions (off the top of my head: childhood immunisations) the opposite is true: the more contact people have with medical services, the more ill they become. And not only because of what the medical profession imposes on them. After all, no sane punter takes time out of their busy schedule for a ‘check’ without getting their money’s worth with two or three ‘while I’m heres’.

So medicalisation leads to more medicalisation. Meanwhile, the genuinely ill simply can’t get seen. Hence frustrating waits for appointments, 111 dysfunction and overflowing A&E. The NHS can only do so much, and we waste so much time trying to keep people healthy that we have no capacity to manage the sick.

Is this what medicine is for? We need to get our priorities right, and we could start by replacing the letter ‘H’ with the letter ‘I’. National Illness Service, anyone?

Dr Tony Copperfield is a GP in Essex. Read more of Copperfield’s blogs at or follow him on Twitter @doccopperfield

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Readers' comments (9)

  • Very well said!

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  • How can you stop/slow it when healthcare is politicised, because it is socialised? Not to mention welfare...

    You vote for smaller govt.
    You advocate for individual responsibility.

    Nothing else works.

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  • Well said.

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  • Prevention is valuable; but we focus far too much on what the NHS can do, and far too little on the wider determinants of health.

    Addressing homelessness and poor services for young people in need, reinstating sure-start, improving local authority funding and opportunities such as better leisure and community facilities, integrating public transport systems and supporting cycling and other systems to counter the obesogenic environment... These are all likely to have a higher yield than much of the secondary prevention undertaken in primary care. Some of them - like improving services for looked after children and young people and for homeless people - might well be cost-saving in the medium to long term.

    Vaccine programmes are worthwhile, of course - they are highly effective and often cost-saving.

    DOI - I haven't managed to get registered on Pulse in an appropriate way. I am a former GP, and am now a public health doc (consultant in communicable disease control) and chair of the BMA Public Health Medicine Committee.

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  • |Peter English | Salaried GP | Surrey|08 Jan 2020 12:39pm

    "might well be cost-saving in the medium to long term. "
    - so you want to do something, which you're not sure of the benefit, paid for by our taxes.... Just like every vanity project by the state then...

    "far too little on the wider determinants of health. "
    - How about the biggest one? The decision to take full individual responsibility for one's health?

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  • I agree Copperfield. Drawing more and more of normal human activity into the health service is madness. Take social prescribers. Someone is sad and lonely, ‘don’t worry the health service can help you!’. We need to persuade the public that the health service is there to deal with health matters, not normal life events, daily misery, loneliness. These problems need to be firmly placed in the remit of other public services or charitable organisations. Otherwise we can’t hope to manage the genuinely sick. And yes, a bit of prevention - encouragement of the support of public health schemes like sure start - but don’t open toddler groups in our waiting rooms - please!!

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  • Brilliant! Yes totally true. Most sensible people should avoid seeing the doctor

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  • Thank you, Tony, I've been saying that for at least 20 years!!!

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  • In my view, there are very few cost effective preventative measures.

    1 Childhood immunisations.

    2 Not smoking.

    3 Taking exercise.

    4 Not getting fat (part of number 3)

    5 Not getting addicted to things (especially with reference to number 2)

    These are cost effective because 2 to 5 can be advised by anyone, not just GPs, and the onus is on the patient, and 1 is NOT a rolling programme with follow ups, regular clinics and monitoring, and drug costs.
    Over the years we have been asked to take on activities that may cost us some time/money in the short term, but in the future we would reap the benefits, eg treating hyperlipidaemia, treating mild hypertension, ckd, osteoporosis, etc, and yet we are busier than ever, and the NHS is broke! The whole idea was based on a false premise, that if these patients didn't suffer what treating x was meant to prevent, that they would reduce their service usage (jargon for 'not bother the doctor') and we would all be happier. The sad truth was that not only are some of these measures not preventing very much (look at NNTs for hyperlipidaemia and mild hypertension) they are also not reducing demand. These things would be fine if they fulfilled their promise of making the population more healthy, and reducing demand, but they haven't and they don't.

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