The pandemic could offer the chance to review our increasing reliance on medical solutions, finds Emma Wilkinson
For years, concerned clinicians have been warning about a healthcare culture in which patients increasingly expect a pill – and a test – for every ill.
They also point to screening programmes put into effect with little evidence – most recently, opportunistic pulse checks for atrial fibrillation as part of PCN service specifications in England.
The impact of overmedicalisation on general practice is hard to gauge. But workload, such as that associated with health checks, statins for primary prevention,1 potentially addictive medicines for chronic pain,2 or incidentalomas thrown up by routine scans3 is likely to be substantial.
But the effect of Covid may offer an opportunity to reassess this culture. The reduction seen in tests, scans and other non-urgent procedures provides a chance for a ‘reset’, as clinical professor of primary care research at Hull and York Medical School, Professor Joanne Reeve puts it.
This has powerful support. NHS England’s review on overprescribing4 published in September 2021 found it remains at ‘unacceptable levels’, possibly accounting for ‘at least 10% of the current volume of medicines’. Its conclusion was most intriguing: ‘Covid-19 has made the case for change even stronger. As we look to learn from what has happened… we need to build in improvements so we reduce overprescribing once and for all.’
North London GP and new RCGP overdiagnosis group chair Dr David Spitzer agrees: ‘Addressing overmedicalisation must form part of the post-Covid recovery in primary care.’
Last year’s national review on overprescribing4, found it remains at ‘unacceptable levels’, suggesting 10% of prescription items in primary care need not have been issued. It concluded Covid-19 had ‘made the case for change even stronger’.
Here we explore the impact of overmedicalisation on general practice, what is being done to learn more and how GPs can push back.
‘The assumption is more is better‘
Dr Jessica Watson, a GP in Bristol and a researcher at the University of Bristol with an interest in the rational use of blood tests, says it’s hard to know whether testing is improving health or causing harm. But she adds: ‘It’s much easier to prove [how it improves health], to look at late diagnosis, so there is always the assumption that more is better.
‘What you often find is you’re filing lots of normal results and wondering why you are doing this in the first place. It can throw up serious things but around 5% will be just outside the normal range and they can be really hard to manage.
‘I do see that where minor borderline abnormalities are picked up on routine screening, we can generate more harm than good and when you start down that road it’s very hard to backtrack.
‘In my own practice we have discussed cases of abnormal test results that have generated anxiety, workload, more tests and waits for patients.’
Dr Watson says Covid has, in some ways, increased caution: ‘There is the worry about missing something and there has been a shift in the pandemic towards wanting to make the most use of a trip into the surgery, so we think, let’s do all of these bloods while we’re here.’
However, in August last year, a test-tube shortage saw GPs forced to stop all non-urgent blood tests for more than a month and then issued with guidelines asking them to consider whether a test was really needed. In December, NHS England removed these restrictions on testing.
Dr Watson says this ‘natural experiment’ could be instructive: ‘It forced us to think … what is really necessary and what other things are actually low value for patients. We can try to get positive lessons about what things we don’t need to do just because we always have.’
Researchers are starting to look at how to rationalise testing. One aspect that is being looked at, says Dr Watson, is whether one-click ordering of test sets (all relevant tests for a particular condition)could help. ‘There is work going on to look at what tests should we all be doing across different monitoring and testing practices, to try and get a better evidence base and consistent approach.’
‘GPs receive data that tells them how much they’re prescribing and at what cost – why not the same for testing,’ asks Salford GP Dr Jane Wilcock, who has an interest in overdiagnosis.
‘We spend a lot of time looking at tests, and doing more tests when actually, there’s not much wrong with them.’
Borderline results, such as a low B12 in a patient who feels fine, or slightly raised liver function tests, can be hard for GPs to manage and stressful for patients, she explains. ‘It can generate a lot of anxiety. People just assume the worst and that takes a long time to unpick.’
SCREENING AND PREVENTION
‘There is wishful thinking that programmes improve outcomes‘
In 2019, a Pulse survey revealed an increase in the type of scans that detect incidentalomas, as well as a sharp rise in the number of scans ordered by GPs.3
North London GP Dr David Spitzer says all GPs have experience of incidentalomas. He recalls a case where a patient had spent a couple of months in the US and been given a CT scan for a cough, which highlighted a thyroid nodule. The patient ended up back in the UK undergoing blood tests, an ultrasound and biopsy, all for nothing.
‘The patient came back to me to have a chat with me about why all this had been done. The biopsy had been very painful and the whole experience very worrying and stressful.’
Controversies around screening persist. Many believe programmes such as routine PSA testing, lung checks and, more recently, opportunistic pulse checks for atrial fibrillation (AF) may do more harm than good and should not be implemented without robust evidence.
Dr Julian Treadwell, a GP and research fellow at the University of Oxford, says the identification of AF in practice is an example of a potentially worthwhile intervention, as people at really high risk of stroke can be found in this way. ‘In selected cases, [AF treatment] is the most powerful preventive prescription a GP can give. There’s obviously been lots of speculation about under-identification of AF.’
A PCN incentive specification, being introduced from April, recommends opportunistic pulse checks. ‘If you interpret this as “check someone’s pulse when doing their blood pressure”, that’s one thing, and probably should happen anyway,’ says Dr Treadwell. ‘But introducing a new process of checking the pulse of everybody over 65 who walks through your door is a different thing.’
He cites NHS Health Checks as another example, saying that while the individual components have good evidence, there is so far no evidence to support a national programme.
Research published more than a decade ago showed that if GPs were to follow European guidelines on hypertension – which used a combined risk model and lowered thresholds – in the relatively healthy population of Norway, it would completely destabilise the healthcare system and require a significantly increase in the number of GPs.
The authors concluded that large-scale prevention projects can only be regarded as ‘scientifically sound’ if they also look at the feasibility in the real world.
Screening programmes that have not been well thought through can have wider impacts, warns Professor Reeve. A good example, is the identification of coronary artery calcification during a lung cancer check, about which the patient’s GP will receive a letter. She says that, while in some areas the letter might specify the level of risk and the recommended medications, in others there is little guidance or rationale.
‘In Liverpool you just get a letter saying this person’s been identified as being at risk. See them and sort it out. There is no evidence and it is classic overmedicalisation. It’s bad medicine and bad science,’ she says, noting that this is particularly serious at a time when GPs are already overworked.
However, due to the pandemic’s impact on healthcare provision, less routine prevention work has been taking place. Dr Treadwell says it will be important to understand the impact of this. ‘Obviously much normal preventive work has not been happening during Covid. It’ll be interesting to see the evidence over the next two or three years about the effect on outcomes that really matter.’
Research has yet to confirm the benefits of routine screening. ‘You have this sort of wishful thinking that if you introduce a screening programme, you’ll find more pathology, you’ll intervene earlier and improve the outcome.’ he says.
‘It’s about saying no‘
Regulatory bodies such as NICE are doing more to promote lifestyle management as well as urging caution about overprescribing and polypharmacy. This is part of a necessary culture change but guidelines are also a manifestation of a wider problem, says Professor Reeve.
‘We train people to adopt guidelines, we reward them or punish them around guidelines, we design consultations around guidelines we’ve designed.’
The focus, she says, should be on providing a system and a supportive infrastructure that allows clinicians to explain all the data around the harms and benefits of potential interventions to the patient and discuss a way forward. ‘It’s the flexibility to say, I don’t have a certain answer here but if we did this, we’d expect to see this. Let’s meet again in a month’s time and check whether that looks like it’s happening.
‘We are never going to have the research that says for this type of person on this combination of eight drugs, this is what’s going to happen. It is always going to be about judgement.’
Dr Treadwell points out there is a lot of work being done to support structured medication reviews and deprescribing. He is developing an online tool to communicate evidence about treatment for long-term conditions to help GPs manage multimorbidity and polypharmacy.
‘It’s taking the evidence behind NICE guidelines and giving information on the benefits and harms in absolute terms. If you can see out of the list of 10 available treatments in the guideline, which are the five most effective, you can think about which ones you keep and which ones you drop. The idea is to make the data accessible and useful.’
The RCGP overdiagnosis group was set up in 2014. Its goal is to disseminate good practice, such as the use of personalised decision aids, as well as involvement in consultations such as those around NICE guidance on shared decision making, which the group believes was an important step in the right direction.
A series of tools and resources has been developed in recent years to help GPs manage overmedicalisation, including quick summaries of evidence-based medicine from The NNT5, and Choosing Wisely6 – a global initiative with a UK arm that encourages conversations with patients about benefits and risks and what really matters to them.
Dr Spitzer, chair of the RCGP group, says some policy changes during the past two years have highlighted things GPs may have been doing that were not worthwhile, and that addressing overmedicalisation must form part of post-Covid recovery in primary care.
‘The obvious thing is QOF – it was partially or completely abolished for a lot of the pandemic. If it was felt to be low priority and could be dropped when practices were under enormous pressure, we have to think very carefully about whether that offers value,’ he says.
Merseyside GP Dr Heather Ryan agrees, saying the GP workforce crisis means ‘we should be focusing on interventions that are effective rather than things that might do more harm than good’.
Dr Ryan adds that in her work as a GP educator, she teaches that only interventions that would change a pateint’s management should be adopted: ‘You shouldn’t do things just because you can. It’s not just about doctor time, but about patient expectation; the more you medicalise things, the more patient expectation rises.’
The Primary Care Academic Collaborative (PACT) has received funding for its Why Test study7, to find out why blood tests are requested in primary care, by whom and what happens with the results.
Other solutions put forward in NHS England’s review on overprescribing4 include systemic changes like improving patient records and ‘culture change’ to reduce the reliance on medicines. The review concluded the coming year will be critical for the success of this work in the longer term.
Various deprescribing tools have been developed for use, with NICE most recently providing advice on discontinuing antidepressants.8 There is also the STOPP-START tool9 developed to reduce overprescribing in frail older patients.
‘[NHS England’s review] says that people don’t have time to push back against it so you won’t get it sustainably yet. But we can contribute to that culture shift by doing it in little pockets,’ says Professor Reeve, who is also doing work on deprescribing in general practice.
‘It’s really about saying no,’ adds Dr Wilcock. ‘Learning to say no, we don’t need to give you a medication, we don’t need to do this investigation yet – and having some confidence in that. There’s also a point where GPs need to say, I’ve completed this interval of care. I don’t think we’re very good at letting people go back into society and be autonomous.’
Top 5 ways practices can help reduce overmedicalisation
1 Audit lab requests
The aim here is to identify circumstances where investigations are clearly needed to inform the care pathway and decision making, as opposed to those where unfocused investigations are requested in the absence of a coherent management plan. Where the relevance of an investigation is not clear, a case-based discussion may be informative.
2 Use an internal referral process to reduce unnecessary referrals
Referral review meetings can be useful to sense-check clinical care and identify any alternatives to referral. While practices may find the majority of referrals are justified, in
a significant minority of cases alternatives may be identified, including in-house treatment or the use of Advice and Guidance pathways.
3 ‘Sense-test’ and adapt national guidance
The frequency and volume of national guidance can make it challenging for busy GPs to keep up to date. Consider assigning broad clinical areas to members of the practice, so they can monitor for any changes. Cascading these and discussing their significance in the practice can be useful for CPD and support referral conversations too.
4 Establish a deprescribing policy
Consider a formal prescribing policy for the practice. This may focus on areas of priority such as controlled drugs, polypharmacy or the elderly. Consider the use of clinical tools such as the STOPP-START guidance.9 Ensure the indication for initiating a medicine is clearly recorded in the patient record; this makes deprescribing much easier if appropriate.
5 Regularly review the work of other professionals in the practice, such as pharmacists and physiotherapists
Ensure allied healthcare professionals are working to agreed care pathways. Case reviews, one-to-one mentoring and referral meetings will help achieve this. Outputs are likely to be as informative for GPs as for the wider team of clinicians.
Dr Jonathan Inglesfield is a GP in Surrey
- Byrne, P et al. Statins for primary prevention of cardiovascular disease. BMJ 2019;367:l5674.
- Medicines associated with dependence or withdrawal symptoms: safe prescribing and withdrawal management for adults. NICE, October 2021.
- Incidentaloma on the rise: how GPs are left to manage unexpected findings. Pulse, July 2019.
- Ridge K. National overprescribing review report. DHSC, 2021.
- The NNT: quick summaries of evidence-based medicine.
- Choosing Wisely.
- Primary care Academic Collaborative. Why Test study.
- Antidepressant treatment in Adults. NICE, 2021.
- STOPP-START tool.
- NHS England, 2021. Diagnostic imaging dataset.
- O’Sullivan J et al. Prevalence and outcomes of incidental imaging findings. BMJ 2018;361:k2387.