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Too much medicine, too little time

Planet Primary Care

I realise that by the time you read this, they’ll be wrapped around your cod and chips, but I’ve just noticed three fascinating news stories. Fascinating, because they encapsulate our current problems.

First, there was shadow health secretary Wes Streeting. In a moment of The Thick of It-style, quick-dream-up-an-idea-in-the-back-of-a-cab inspiration, he envisaged this: an app that, post knee injury, logs that you’ve been moving less than you should and so push-notifies the suggestion that you should see your GP for pain management. Genius – and why stop there? Why not an app that detects if you’ve not moved for weeks, and then sends the GP an alert that you’re probably dead, with a pre-filled crem form?

Second was the news that yet another novel and expensive cholesterol-lowering agent is being unleashed. Jeez. Statins and ezetimibe I can cope with. Beyond that, I’m lost. And it’s the same with everything else these days: COPD, asthma, diabetes. Too many options. Diabetes? Remember the halcyon days of diet/metformin/insulin? When diabetes was just diabetes, with no shades of grey? How I long for that pre-pre-diabetic time. That’s an era, not a new disease, by the way.

And third was the well-publicised recording of the nurse explaining that the waiting time in A&E is longer than the average life expectancy of the people waiting there, sending the Mail’s trigger finger of blame back in the direction of us GPs, of course.

So there we have it, a summary of where we are. Infantilise and overmedicalise the public, then wonder why we’re all drowning in work.

Don’t worry. This isn’t yer standard-issue reorganise the NHS rant. No, it goes much deeper than that. It’s the whole of medicine that needs a reboot: what it’s for and what it can reasonably be expected to do.

I don’t have the answers (obviously), but that doesn’t stop me posing the questions. And the debate should be underpinned by two key principles:

  • A recognition that people don’t value their illnesses as highly as we doctors do. They don’t want to be defined by their pathology, they don’t want it to dominate their lives and they don’t want to jump through any of the absurd hoops we set for them (asthma QOF, anyone?). Hence patients defaulting on appointments, undermining chronic disease management plans, and not taking their meds.
  • An understanding of the law of diminishing returns. ‘Good enough’ care is achievable, excellence isn’t. In fact, the pursuit of excellence requires disproportionate effort while reaping little extra benefit – with blistering implications for costs, medicalisation and our sanity. Besides, most people don’t want to live forever, and if we insist they do, all the cost-effectiveness arguments blow up in our faces, eternal life being infinitely expensive.

So we need a big rethink, with an acceptance that we should stop pushing medicine (in the widest sense) because patients don’t want it, it probably won’t help and it may even make them iller. Plus it cranks up the pressure: yes, it’s true, probably half our workload is self-inflicted. A revolution, then, if you want. 

I won’t be putting anyone up against the wall, but I will be prescribing fewer lipid-lowering drugs. I can’t wait, even if those in A&E have to.

Dr Tony Copperfield is a GP in Essex. Read more of Copperfield’s blogs here

READERS' COMMENTS [7]

Paul Loxton 1 July, 2022 12:07 pm

Well said .
QOF is a failed experiment.There is no evidence of any benefit and it encourages over -diagnosis and over -treatment. It uses upper an enormous amount of clinical and administrative time .
Similarly endless guidelines and slavish adherence to them has a similar effect with little consideration for the problems of individual patients and more unnecessary prescribing.
No wonder that evidence for compliance for prescribed medication is at best around 50%.

Decorum Est 1 July, 2022 3:23 pm

If ‘the waiting time in A&E is longer than the average life expectancy of the people waiting there’, then shouldn’t there be an immediate health warning about attending? 🥸

Dylan Summers 2 July, 2022 8:32 am

“‘Good enough’ care is achievable, excellence isn’t.”

Absolutely. And the futile pursuit of excellence eats up the resources that could be providing good enough care.

Peter McEvedy 2 July, 2022 11:05 am

A while ago when I was on a committee, we looked at our diabetes results for the area. At the time we basically followed the diet, metformin, insulin approach with a bit of gliclazide when insulin not wanted. We were shown on one of those trumpet diagrams as having some of the best outcomes at the lowest cost. We had a consultant who followed the same mantra and all went well till he retired. I don’t think our results are any better really but we now use a multitude of drugs and out costs are huge. Progress I suppose.

Patrufini Duffy 4 July, 2022 4:18 pm

Most of us are still on slide 324 of level 3 safeguarding. And paradoxically completely disempowered by that process. And page 47 of the new guidelines of switching sertraline to the latest e-sertraline. Page 47 is ofcourse only online if you can remember the login and password for the 823rd site where key information is held. For a national state system, without anything coherent beyond a guaranteed sell off.

Richard hattersley 7 July, 2022 9:29 am

Excellent article. I agree with a full re boot concept driven by GPs. If it back fires it will be the end of the general practice we trained for. If we let it run we will lose General practice.
I agree with the two principals and these are the key.

Truth Finder 18 July, 2022 10:13 am

Excellent article. The NHS has lost the plot. We should not be participating in it. Basic “good enough” healthcare is not even achieved and they want the pretentious “excellence”. The NHS is anything but excellent.