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Give us the time to help people place their health bets

Dr Shaba Nabi

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I’m writing this blog after screaming at the telly as the Public Health England’s chief executive told us we need to ‘know our numbers’. He meant our cholesterol and blood pressure readings, but other numbers are far more important.

The numbers people really need to know are their odds of having a heart attack or a stroke – and this is an area where GPs genuinely are best placed. So if the Government wants to reduce health spend and improve outcomes, it needs to value the GP consultation more.

Effective consulting needs to place the person at the heart of decision making – to give them enough evidenced-based information to steer their own health journey.

But let’s reflect for a minute on how we do this. We enter data into computers, which immediately ping up messages about starting medications, ruling out sepsis or fast-tracking an urgent cancer referral. We dare not ignore these messages, as once triggered, they are immortalised in the notes, and could come back to bite us in court.

But what do all these guidelines mean to individuals? They don’t care that lowering average blood pressure will reduce stroke incidence in a particular population. They want to know how much they themselves will benefit (or be harmed) by a treatment, screening or intervention. They need to reflect on their one in 100 chance of preventing a heart attack, in exchange for the one in 10 chance of tiredness or swollen ankles with another antihypertensive. They need to know if five fewer trips to the bathroom per week is worth the dizziness and dry mouth an anticholinergic may bring. And most importantly, they need to be aware of the psychological impact of being turned into a patient through lowered disease thresholds and indiscriminate screening.

What we all really want to know is, what are our health gambling odds?

How do we facilitate their decisions? Sadly, we’re lacking in this knowledge ourselves. My trainees are well versed in NICE treatment thresholds, but none of us is confident to inform someone of their individual risk. What we all really want to know is, what are our health gambling odds? If I don’t take this statin, how much more likely am I to have a heart attack or a stroke? If I undergo back surgery, what is the likelihood of a pain-free existence? And if I enter a breast screening programme, what are my chances of being diagnosed with a cancer that would never have killed me?

What we need to reduce overdiagnosis and overtreatment is a health betting shop where we can clearly see our odds and place our bets accordingly. Instead of being bombarded with yet more guidelines, we need an intelligence platform where people can confidently select their treatment choices according to their personal values.

But most of all, we need longer consultations. If GPs had the time to practise shared decision making, we could reduce much of the low-value activity that costs the NHS millions. Urgent investment is required to enable longer consultations, and it is regrettable that this has not been mandated in the new GP contract.

People would not be harmed, and doctors would be far more satisfied and less burnt out. It really is that simple.

Dr Shaba Nabi is a GP trainer in Bristol. Read more Dr Nabi’s blogs online at pulsetoday.co.uk/nabi

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Readers' comments (6)

  • "But most of all, we need longer consultations."

    That assumes that GPs are the right people to do the work of discussing risks and benefits. But I had an hour-long meeting with a financial advisor yesterday and it occurred to me that the conversation we had was the same sort of conversation about long term priorities, risks and benefits.

    Maybe this is indeed the proper role of the GP, but:

    1. We can't spend an hour making a personalised preventative plan for each patient. There is no version of the NHS in which that is going to be an option.

    2. If a personalised plan is needed (and that's a big "if"), is a medical degree needed to provide it?

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  • Yesterday spent the hours between 11-3.30 doing “Telephone triage” which was in reality sorting out complex patients each call lasting 15-25 minutes, realising that the only clinician who understood the wide needs of the patient was me,the only service that couldn’t turn the patient away was mine, the only person who had a real vested interest to reduce the revolving door was me and I’m the one who had the least time (5 mins) for triage. And yes I was the best person as these patients have nurse specialists in hospital, “ key workers” ( don’t make me laugh) none of whom were able to provide expertise or compassion. Dr Nabi is completely right because even the seemingly straight forward patient requiring statin counselling - if not done properly ( “ the statistics show... but the statistics are not about you personally”) will end up coming back to our doors several times unless we can have those discussions properly. The problem with the current situation of exponential increase in workload is that unfortunately to do the job well you keep having to go the extra mile and if you do that, you eventually run out of road. The casualties of this system are the loss of experienced highly skilled GPs and quality of patient care.
    And by the way I don’t think there are any other healthcare professionals working today who could have achieved what I was able to do in a 15-25 minute phone call that’s why patients love their GPs- they are not daft. Pity I only had 5 minutes to do it

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  • Shaba - remember to place a bet in any other situation you have to pay financially for it. And until you do so, you would not really understand the full implications of the bet, e.g. the cost of being on lifelong statin, or bp meds, etc . And none of this, 'I pay my taxes nonsense'. If you make more than the average individual income in the UK, you're essentially paying for someone else's healthcare, which also means that if given a choice, I BET that the vast majority of taxpayers would opt out of the tax contribution (approx. 30% of what you pay in tax) that goes to the NHS, and simply pay for comprehensive private medical insurance at a fraction of that. Guess what happens in most of the rest of the world without universal comprehensive healthcare? People make truly informed individual choices about their 'preventative' healthcare, bearing in mind the costs, and are more motivated to lead a responsible lifestyle to reduce their modifiable risks, and to provide for the costs.

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  • Christopher Ho.
    Nothing in life is truest black or white. Privatised is no better than socialised. Ideal is something in the middle.
    Also, do you really think that the government will give you back any money if you pay for your health care?

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  • @cavalry - I agree, I never said that I'm for 100% individual responsibility. I could be amenable to having emergency treatment covered, and partial subsidisation of access to primary care and prescriptions. We clearly have leaned too far in the other direction though. Privatised or as free a market in any industry, has many benefits over socialisation though. Ideal is not halfway. When did I say I want the govt to give me back any money? I don't want them to take it in the first place.

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  • I direct people to the numbers needed to treat website - thennt.org - and let them make their own decision. The problem is the Stalinist (collectivist rather than individual) approach to medical care that current medicine seems to demand. I think of the current approach to AF detection and treatment which is much in vogue (to the benefit of big pharma). Please don't get me wrong. There are those with AF who will benefit from anti-coagulation. But do we really involve patients in the decision making process to start it? Do we really treat people as individuals?

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