95% Less Harmful – the Story of a Statistic

When Public Health England (PHE) published their recent report on e cigarettes, the statistic to hit the headlines was the claim that the electronic variety were ‘95% less harmful’ than standard cigarettes. It’s a figure that will have entered the collective consciousness of journalists and vaping enthusiasts, and I can guarantee that we will hear it quoted again and again in coming months and years.

The question is: where has it come from, and what does it mean?

The first question is easy to answer: the 95% figure does not come from PHE. Their report simply quotes the estimates made by another group of experts published by Nutt et al in European Addiction Research. Simply put, PHE have said: ‘other experts have guessed that e cigarettes are 95% less harmful than standard cigarettes, and that seems about right to us.’

The over reliance on the findings of another group of experts has received some very public criticism – most notably in an editorial in The Lancet when it emerged that the findings of this group had been funded by an organisation with links to industry, and that three of its authors had significant financial conflicts of interest. These are valid points, although they may have been made better if The Lancet had included the author’s name and declaration of interests alongside the editorial.

The second question is harder to answer, and here is my main concern with how the 95% figure has been presented. What does ‘95% less harmful’ actually mean?

If I were a smoker, wondering whether to switch to vaping, I would primarily be interested in one thing: how harmful are they to me. In other words – am I less likely to die or get ill if I switch to e cigarettes?

Well, the PHE report would seem to answer this question – in the forward to the full report the authors state that e cigarettes are ‘95% less harmful to your health than smoking.’ The trouble is that the report where they obtained the 95% figure looked at far more than just the effects of smoking on the health of an individual.

The piece of work by Nutt and colleagues involved a group of experts being asked to estimate the harm of a range of nicotine products against 12 different criteria – these included the risk to individual health, but also other societal harms such as economic impact, international damage and links with crime. The 95% figure was only achieved after all 12 factors were weighted for importance and then each nicotine containing product was given a composite score.

Now the propensity for a commercial product to be linked with criminal activity may be very important to PHE, but it wouldn’t influence my individual health choice, nor the advice I would want to give to patients.

Moreover, the work by Nutt and colleagues includes this statement: ‘Perhaps not surprisingly, given their massively greater use as compared with other products, cigarettes were ranked the most harmful.’ So the research was greatly influenced by the extent to which products are used. On this basis you could conclude that drinking wine is more harmful than drinking methylated spirits – on a population basis this is true, but it would be a poor basis for individual advice. 

In response to the criticism in The Lancet, PHE produced a subsequent statement in order to try to achieve some clarity over the 95% figure – only to muddy the waters further by claiming that the figure was linked to the fact that there are 95% fewer harmful chemicals in e cigarettes than standard cigarettes. This may well be true – but it is not the reason why they gave the 95% figure in the first place. It also assumes a linear relationship between the amount of chemical and the degree of harm – 5% of the chemical might only cause 1% of the harm, or it could be 50%.

One of the main problems I have with the 95% statistic, therefore, is one of principle – I just don’t like being duped by the misuse of statistics.

My second issue, however, is more pragmatic: the statistic does not help us with some of the key questions we need to answer.

That e cigarettes are safer than standard cigarettes is not much in doubt – mostly on the basis that smoking is so bad for health that it isn’t hard to beat. There is clearly much to be gained by smokers switching to the electronic variety. The next question concerns what smokers should do next.

Much is said about e cigarettes being an aid to quitting, but what is unique about them is that people often stay with them for the longterm, in a way that they would never consider with something like a nicotine patch. This may be their greatest strength – people may be able to quit who could never do so before – but it is also a new phenomenon as longterm nicotine substitution becomes the norm.

Are e cigarettes so safe that once smokers move over to them they can consider the job done? Many vapers talk about it in these terms. For the short term, it seems they are safe. They have been in common use for 5-8 years and there have been no major concerns so far (although acute poisoning is a new problem with liquid nicotine) – but then the same is true for cigarettes where it is use over decades that is the problem. For me, the 95% figure is too questionable to be able to help here.

There are more dilemmas I face as a doctor since I need to know how to interpret the health risks of someone who uses an electronic cigarette. When it comes to cardiovascular risk, should I consider them a smoker, a non-smoker, or something in between? If they have a persistent cough, do I suggest a chest x-ray early on the grounds that they are at increased risk, or can we watch and wait for a while?

We are a long way from being able to answer questions like this, and I would have preferred a little more honesty from PHE about what we don’t yet know, a little less reliance on the opinions of experts, and only to be presented with a figure like 95% if it is based on hard, objective evidence.

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I haven’t Been Paid to Write This

There were two items in the news last week that created an interesting juxtaposition on the issue of transparency.

The first concerned the new guidelines for Vloggers – those entrepreneurial YouTubers who have managed to create a following by recording short video clips of their lives, hoping to earn a few pounds along the way.

Some, it seems, have been earning extra money by being paid to recommend products to their viewers – Oreo biscuits being the most high profile example – and such is their influence that new rules have been established to make sure the unsuspecting public know money has changed hands. In short, they can recommend anything they like, but must make a clear declaration if they’ve been paid to do so.

The BBC news cheerfully put together item where three young female Vloggers dutifully explained the new rules, gaining some useful exposure for their own YouTube channel along the way.

You can hardly object to the rules; transparency is important and the consuming public should not be misled.  These young women hardly seemed to be a major threat to society, though, and you couldn’t help thinking that the establishment had come down hard on some enterprising young people who had found a way to start saving for a mortgage.

The second item concerned e cigarettes. Public Health England had produced a report stating that e cigarettes are ‘95% less harmful’ than standard cigarettes and suggesting that they should be prescribed on the NHS in the future.

The report is not a new study, but the opinion of a group of experts who have looked at all the evidence that is out there and given us the benefit of their combined wisdom.

Now, when a Vlogger declares one brand of biscuit to be superior to another, we have a right to know whether or not they have any financial incentive to say so; as Shahriar Coupal, director of the Committee of Advertising Practice says: ‘it’s simply not fair if we’re being advertised to and are not made aware of that fact.’

So what if a scientific expert declares one type of cigarette to be safer than another? Do we not have the same right to know whether the expert has had any financial dealings with the makers of cigarettes? Good medical practice would certainly say so, but the practical reality is often very different.

I have looked at the report in detail. The names of the authors are clear, but nowhere in its 111 pages can I find any declaration of interests; I have no way of knowing whether or not these authors have been paid by the makers of e cigarettes.

Which is more important? The type of biscuit someone may buy after watching a video on YouTube, or the health advice given to the nation by Public Health England on something as topical as e cigarettes?

I’m not stating that the authors do have any conflict of interests – they may well be entirely free from such ties – but the issue is that I cannot tell. If they have no such links, then tell me – I will be far more willing to trust the opinion of these experts if that is the case. If, on the other hand, they have received money from industry, then I have both a right and a need to know – for the sake of my patients and the advice I may pass on to them.

The authors may have made declarations of interests elsewhere, but this is no good to me since I don’t know where to look, and anyway, why should I be required to hunt for them? The Vloggers have to make a declaration on the page where they advertise the product, it should be no different for Public Health England.

Why are these declarations so often absent in reports like this? Is it thoughtlessness, laziness, or something more sinister? I don’t know, but it should be different. We need a culture change until it becomes unthinkable to publish such a report without them. We need a media that will focus the story on the lack of such a declaration rather than on the report itself – which is, after all, meaningless without it.

So what do I think of the report itself? Sadly, until I know if I can trust its authors I just don’t think I can make a judgement.

Addendum

As you will be able to see from the comments below, Public Health England have amended the report to include full DOI on pages 90 and 91 which is great news!

Nagging Never Works

During my time working in hospital I remember seeing a patient in the clinic who came for review after a spell as an in-patient. He had come in with his first episode of chest pain caused by heart disease and he had made a good recovery. What I remember most about him, however, was how emphatically he wanted me to pass on his thanks to the junior doctor who had admitted him:

‘She saved my life, doctor,’ he said. ‘She told me I’d die if I didn’t stop smoking. You know what I did? I handed over my packet of fags and haven’t touched one since; best thing that could’ve happened to me!’

I reassured him that I would certainly pass on his thanks to the doctor, and was glad for his success; what I did not tell him, however, was that my colleague had smoked every one of his cigarettes – ‘shame to waste them,’ she had told me.

What this incident illustrates is the fundamental difference between being in possession of medical knowledge and deciding to act upon it – or in the language of the cycle of change: moving from being pre-contemplative about change to actually contemplating doing something. My medical colleague undoubtedly knew more than most about the risks of smoking, yet she persisted despite the urgent advice she gave to her patient; the presence of crushing chest pain, however, was clearly capable of bringing the same advice into such sharp focus that it motivated radical change.

I often say to my patients that their two best opportunities to stop smoking are to get pregnant or to have a heart attack – a range of options which my male patients find disturbingly limiting. Timely advice from doctors can certainly increase the chance of success, but the studies included in the Cochrane review are of interventions when patients have made an appointment for other reasons. A different question entirely is whether or not we should screen for cardiovascular disease and then provide lifestyle interventions – and the answer to this has appeared in the BMJ recently, and appears to be a resounding ‘no’.

The Inter99 study is a significant piece of work – nearly 60 000 participants with interventions over 5 years and 10 year follow-up, and came to the overwhelming conclusion that screening for risk factors with regular lifestyle counselling had no impact on the incidence of ischaemic heart disease, stroke or mortality. We might be depressed at the poor return for such well-meant efforts, but we should not be surprised: despite the Government’s obsession with ‘making every contact count’, NHS health checks and annual demands in the GP contract to advise our patients again and again about smoking, nagging patients generally does not work.

We know nagging does not work because that is what patients say – receiving health advice when you are not ready for it simply creates resistance and can damage the doctor-patient relationship as this qualitative study in smokers makes clear; it is contrary to all the principles of Motivational Interviewing and against both our training and our experience in the consulting room. The question now is, will policy-makers listen? Will they be bold enough to follow the evidence and stop telling doctors to do things that don’t work, or will they just carry on regardless? Sadly, I think I might know the answer.

This post was first published in Pulse magazine (free subscription required)

Raising Awareness – Do We Know What We Are Doing?

There was an interesting discussion on Radio 5 Live recently between Glasgow GP Dr Margaret McCartney and Kris Hallenga, the founder of the CoppaFeel breast cancer awareness charity. The interview was arranged in relation to an article Dr McCartney wrote for the BMJ in the first of her new weekly column for the journal, which criticised The Sun newspaper’s rather hypocritical Page 3 campaign to encourage young women to regularly check their breasts for lumps. Whatever you might think of the piece, you have to admire Dr McCartney’s boldness for taking on both a national daily newspaper and the emotive power of the Pink Ribbon for her induction to the column!

The interview exposes how screening for disease and responding to symptoms are so often blurred in the media and by health campaigners – whether this is due to simple ignorance or a deliberate ploy to increase the power of the campaigns is uncertain, but that it is helpful is without doubt. The Sun’s campaign calls for the screening of asymptomatic women through regular breast self-examination, and Dr McCartney’s assertion is that the benefits and harms of this strategy are not sufficiently understood to be able to promote such advice, and what evidence we do have suggests it may do more harm than good. Ms Hallenga, on the other hand says that she ‘ignored her symptoms for so long’; ignoring the symptoms is not the same as failing to remember to check yourself when you don’t have symptoms – there is something more going on here, which brings me to a fundamental problem with ‘awareness raising’ health campaigns.

The logic of raising awareness goes like this: people aren’t seeing their doctor quickly enough about a certain disease – this must be due to a lack of knowledge, understanding and awareness of the condition – there should be a campaign to raise awareness – people will be better informed and see their doctor more quickly – lives and money will be saved. If we were all computer programmes and responded in a predictable way to data input this would work a treat, but people are far more complicated than that.

There are many reasons why someone may choose not to see their doctor when they have significant symptoms. Ignorance may be one of them, but in this day and age of instant health information courtesy of Google, it is surely less of a factor than it used to be – the danger is now the converse, that too much information may be having a detrimental effect. If a woman finds a breast lump – whether by chance or through a belief that she should check herself – she is unlikely to be unaware that breast cancer is a possibility, and yet some will delay seeing their GP despite this knowledge. Other factors must play a part: fear of what might happen next; complex self-denial as we convince ourselves that ‘this can’t be true’; embarrassment; business and the attitude that ‘I haven’t got time to be ill’ are all reasons why someone may not see a doctor – attitudes that might be improved by an awareness-raising health campaign, or might just be hardened by it.

Awareness raising is usually championed by politicians whose motive is to improve a statistic or – for understandable reasons – by those with an emotional connection with the disease in question. The problem with this is that the focus is heavily biased towards those with the disease, with little consideration given to the potential harm to others who may be caught up in the campaign. The justification for this is often that it brings reassurance to those who are checked out and found to be ok – but we should question the merit of a campaign which brings peace of mind to those who have been made anxious by the very same campaign in the first place.

The ‘cough for three weeks could be cancer’ strategy is a good case in point. As with all GPs I have seen more patients with a cough since the adverts appeared – usually non-smokers who are very conscious of their health and would never ignore symptoms for very long – while I am aware of smokers who have been put off seeing their GP by this very campaign because they don’t want to be given bad news. There is rarely any attempt to see how people will respond to these health messages – little consideration given to the fact that the same message might harden the resistance of those who should seek advice while unhelpfully altering the health-seeking behaviour of those who should not. We need to be bolder in challenging this, even if, like Dr McCartney, we end up being accused of acting ‘dangerously’.

Sometimes, though, if you can’t beat them you have to join them, and so I would like to launch my own awareness raising campaign. It’s very simple and it goes like this: ‘Health Awareness Campaigns can do more harm than good – use with caution, apply common sense, and trust your instincts’.

This post was originally posted in Pulse magazine (free subscription required)

Turning People into Patients

The NHS England campaign ‘The Earlier the Better’ truly baffles me. I have read through the advice to patients, and the document explaining its purpose and justification – I remain perplexed, puzzled by how on earth anyone could think this would help and by the reversal of years of public health information encompassed within its message.

The earlier the better is a seductive strapline in healthcare – and it works well for some conditions, such as meningitis or a heart attack – but it is a peculiar mantra to apply with such a blanket approach. For instance, one of the key pieces of advice this campaign delivers is that if you have a cold you should tell your family, or speak to a pharmacist before it gets worse – the earlier the better. Really? Haven’t we spent years trying to teach people that colds will get better on their own, don’t need treatment and cannot be treated anyway? How, exactly, can a pharmacist help to ‘stop it getting worse’? Sure, they can help with symptom relief for a self-limiting illness, but where is the need to urge people to go early for symptom relief? ‘Fed up with your cold, why not see a pharmacist?’ might have been a more realistic campaign slogan.

Is earlier always better?

The aim of the campaign, apparently, is to reduce winter pressures on the NHS – in particular trying to prevent the elderly from ending up in hospital with respiratory illness. There is nothing a pharmacist can issue without a prescription that will prevent an elderly person developing a secondary pneumonia when they have a viral illness – so the best they can do is suggest someone sees their GP to consider antibiotics. There is a point where timely use of antibiotics might prevent a hospital admission, but even here the earlier the better is simply not true. Treat every cold in the over 65s with antibiotics and the harms of over-using such drugs will outweigh the small number of pneumonias you prevent – a health message that every cold needs prompt action is simply misleading and could be harmful.

For a long while I have been concerned that, as a nation, we have lost our nerve when it comes to assessing our own health. I am confronted by this whenever I see a child bouncing around my surgery room, afflicted by a cold but clearly not unwell, and am asked to ‘check them out, just in case’; or someone is brought to me within an hour of a minor injury or the lightest bump to the head for the same reason. I don’t mind doing this, but I wonder how we could better empower people to assess their own health and feel more confident in their ability to tell when seeing a doctor will be helpful, and when they are absolutely fine on their own. However we do this I’m quite sure that this campaign, with its emphasis on seeking advice from a health professional as soon as you feel even vaguely unwell, is not the way.

What is more, the campaign is mind-numbingly simplistic in its understanding of the causative factors leading to poor health, especially in the elderly. Take the advice on keeping warm, for instance. Of course cold weather is a significant factor in morbidity and mortality in the elderly, but are we really to believe that the major factor influencing the impact of cold weather on the elderly is that no-one has ever suggested they wrap up warm? Might not fuel poverty, social isolation, loneliness and mental health problems have a little more to do with it? And as for eating well as a way to stay healthy – do we really want to insult the over 65s by suggesting that they haven’t lived long enough to work that one out for themselves?

The problem with this campaign is that while the health advice is relatively innocuous, the message that will stick will be the strapline. People who were perfectly happy to care for themselves will see their pharmacist ‘just in case’; pharmacists, good as they are will refer some of these people to their GP ‘just in case’, and another person with a self-limiting illness will have been turned into a patient, and will go home with the belief that they needed to see a doctor, and a little less empowered to care for themselves the next time.

This post was initially published in Pulse magazine (free registration required)

10 Minutes for the Patient

Mr Jones comes to see me. He is only 62, but has high blood pressure, had a stroke two years ago and still has a noticeable limp as he walks down the corridor to my room. Like most patients, Mr Jones knows that he has 10 minutes for the appointment and has spent the time in the waiting room wondering how best to use it. His knee has been bothering him for a while and he has decided it is time to bring this to my attention, but he also knows that his review is due and he won’t be able to leave my room without having had his blood pressure taken.

What Mr Jones really wants to talk to me about, though, is that he’s been having trouble maintaining an erection. He’s not quite sure how to broach that subject, so he plays safe, taps his knee as he sits down and opens with ‘It’s this, doctor. Giving me some trouble, that’s the main thing.’

Like any good GP I clock that if the knee is the main thing then there must be something else as well, and make a mental note to come back to that later – but his blood pressure check is flashing on my computer screen, vying for my attention.

We talk about the knee for the first minute of the appointment, and then I reach for the blood pressure cuff. There is a good reason to tackle this first, since getting him up onto the couch to examine his knee might adversely affect the reading. The numbers are the same as last time – 145/85 – which is a bit awkward, as six months ago this was ok, but in the meantime the Government has changed the goal posts. Now the target is to get blood pressure below 140.

2 minutes

We spend a couple of minutes talking about this, discussing his medication and why we might need to increase his treatment. Since he’s not keen on extra medications – and I’m not convinced about the new target – we decide that he will borrow one of the practice machines and check his blood pressure at home. I wonder if I have just put the problem off for another day.

4 minutes

The amended blood pressure target is not the only new directive to be imposed by the Department of Health this April, so there are more boxes to tick before we can get back to the knee. There’s the new activity questionnaire for starters. Making some assessment of exercise has its place, but I am now required to ask the same questions of all patients with hypertension, however appropriate – or not – it might be. It seems wrong when I ask Mr Jones how much vigorous exercise he undertakes, and he becomes defensive when I enquire how many hours per week he spends doing housework, but we battle through. The advice we receive on the administration of the test states that it takes 1-2 minutes to complete; by the time I have added advice to do more exercise, and received the inevitable reply that this is not easy with only one good leg, that’s a fifth of his appointment.

6 minutes

We return to more familiar territory – I need to ask about smoking – we both know we’ve been here before when I ask if he’s still smoking. He shakes his head and replies: ‘Not the right time, doc.’ The expression on his face asks why I keep going on about it, when he’s made it quite clear he has no intention of giving up.

‘Have you any concerns about your memory?’ Mr Jones is a little taken aback, as he’s not heard this one before, but he is in an at risk group for dementia and so this is the question I am required to ask. It could have only taken a moment – a simple ‘no’ and we move on – but who doesn’t sometimes forget things? Mr Jones occasionally goes into a room and forgets what he’s gone there for – is that what I mean? It takes a little while to explore this further before we both decide that he is not showing early signs of dementia. He taps his knee.

8 minutes

There’s a blood test to sort out. He’s on a statin for his cholesterol, and although the guidelines I read tell me not to perform regular cholesterol checks once treatment is stabilised, the GP contract insists that I check it annually. Still, I like to keep an eye on his kidney function so it’s not entirely wasted. The forms take a while to print out.

‘Do I have to fast?’

‘No, that’s ok’

9 minutes

There’s not enough time to get him up on the couch to examine his knee properly, but I know he’ll need an x-ray to look for arthritis so I do a quick examination in the chair and print another form for him.

10 minutes

I have forgotten that the knee was only the main thing and make it clear that the consultation has ended. Mr Jones leaves with the forms. He’s happy with the x-ray, but he’ll have some explaining to do for Mrs Jones when he gets home. He’ll say the doctor was very busy and promise to ask next time.

The 10 minutes belong to the patient.

We need to give them back.

Mr Jones is not a real patient, but I know of many who share some of his frustrations.

Who Gave Tesco the Right to Shape Our Children?

I clearly missed the moment when we decided to appoint supermarkets as the powers that should determine our social norms, but it has become clear recently that this mantle has been assumed by at least one of these marketing giants. My attention was drawn to this when the campaigning organisation Let Toys be Toys discovered that Tesco was advertising its chemistry set as ‘for boys’, while its Hotpoint cooker was labelled ‘for girls.’

We need to stop and think about this for a moment – if it does not shock and outrage us in the 21st century, then it certainly should. Surely we have moved on from any suggestion that chemistry is only for boys (were the struggles of Marie Curie and Rosamund Franklin for nothing?) And as for the kitchen…

Can we imagine a school separating children by gender in this way? There would be outrage, surely? Even Michael Gove would think it was old-fashioned!

What is revealing is Tesco’s defence of their actions. When Let Toys be Toys challenged them about the signs on Twitter, they replied with:

@lettoysbetoys Toy signage is currently based on research and how our customers tell us they like to shop in our stores

— Tesco Customer Care (@UKTesco) May 4, 2013

So, what they are saying is that they have conducted market research and that is what dictates their policy. The fact that any ethical analysis of the situation can only conclude that toys do not need to be defined by gender apparently has no bearing – the market research (in other words, what sells) trumps any social obligations Tesco might be troubled by.

After some outrage on Twitter (helpfully stimulated by Ben Goldacre) the Tesco account went mysteriously quiet. Subsequently they have apologised for ‘causing upset’ (always apologise for upsetting someone, never for being wrong) and have promised to update the chemistry set as being ‘unisex.’ This they have done, while the kitchen remains distinctly ‘for girls.’ The kitchen is pink – shocking pink – is that enough of a reason to label it for girls, or should we question why on earth a kitchen should be pink in the first place? The answer is clear from the description of another kitchen in the same range:

It’s not about pink then…

Since then there has been media attention, and Tesco have apparently stated on Watchdog that they will ‘be conducting a review of the way it categorises its toys.’ Why a review and not just an apology and immediate change? Is it that hard? They have decided to change the chemistry set without requiring a review, but I can only assume that working out how to categorise a ‘Wild physic and chemistry set’ is more complicated, since it remains like this on their website:

Why does this matter so much? And why talk about it on a health blog? Well, I don’t think we should under-estimate the subversive influences on how we shape our children, or the impact that this will have on their subsequent health as adults. Educational attainment is closely linked to health, and being told you can or can’t do something could have an enormous impact on a child. If parents wish to point their boys towards science, and girls to the kitchen, then that is something I may not agree with (my father is a chef, my wife a scientist, so I’m hardly likely to), but neither should I interfere in another’s parenting without very good reason. Tesco, on the other hand, are not parents and should not presume that they have the right to stereotype in this way.

And when it comes to stereotyping, it is not just how we educate our children that matters to health, but how we feed them. It is nearly a year since Tesco assured me that they would remove the direction to ‘Children’s cereals’ from all their stores, after I pointed out the harmful health message implicit in the signs. Well, as for my local store, I am still waiting…I imagine they are busy conducting a review.

Choices, Choices , Choices

Choice has become a mantra within the public sector, a sine qua non, an indisputably good thing. Politicians are so entranced by its allure that they are blind to both the inherent paradoxes and blatant inequities that are frequently the close companions of choice. The result is that we are often left feeling let down and oddly disempowered.

There are three main types of choice within healthcare: Those that are promised to all but only available to some; those we don’t like to talk about, because the reality is that they aren’t available at all; and those we could all have, but that the powers that be prefer not to tell us about – because they don’t trust us to make the right choice.

The first type of choice we might call the big slice of cake choice. When my teenage son and I cut two slices of cake, inevitably one is larger than the other. With equal predictability, since we are rather partial to cake, we both choose the larger piece – but the reality is that only one of us can have it. Similarly in healthcare – the best surgeon cannot operate on everyone, but who would ever choose the second best? Or I might like to choose the beautiful new hospital on the other side of town, but I have no car and the bus only goes to the tired old DGH down the road.

The result of these big slice of cake choices is that only those with the wherewithal to navigate their way through the confusion of options, and are both savvy and mobile enough to take advantage of the range if choices on offer, will actually benefit – which usually equates to the better off and the less unwell, yet another example of the inverse care law in action.

The second type of choice is the one we like to brush under the carpet – the unpalatable lack of choice that we have to face due to the reality of rationing. The NHS can no longer afford to say ‘yes’ to every health choice we would like to make. The latest, most expensive drug may not be available to us, and our varicose veins may not be deemed worthy of treatment. We are getting used to this in the NHS, and should not be embarrassed by a degree of rationing – although the decisions about what we can and cannot choose need to be made ethically and carefully, and not just by a board of panicked managers frantically trying to balance the books.

The third type of choice is the one that really interests me. It could and should be given to us all, and yet it is rarely talked about – because it has little political value, and involves actually trusting patients. If you are going to trust patients, you have to accept that they can be irrational, unpredictable, and sometimes make foolish choices – and here I speak not as a doctor frustrated by his patents, but as a member of the human race celebrating our glorious diversity.

The choices I am talking about here are these: Should I take a tablet for my mildly raised blood pressure? Should I have a mammogram? How do I feel about statins? These are the sort of health choices many of us are faced with when we visit the doctor, or receive a letter in the post inviting us to engage in a health screening programme. And yet it is rarely presented to us as a choice. We are told to take this tablet, made to feel irresponsible if we ignore the invitation letter, and risk being branded as non-compliant if we disagree – as though it is our duty to bend to the will of the medical profession.

This lack of choice is enshrined in the fabric of the GP contract, as GPs are given an ever-increasing number of targets to aim for – including achieving tight blood pressure control, prescribing anti-coagulants or performing cervical smears. Pressure to deny patient choice comes in the form of prescriptive guidelines, which are frequently dictatorial in the manner in which they tell doctors what they should be done in a particular situation. While evidence-based guidance has been an invaluable tool in helping to achieve excellent standards of care, the words ‘depending on patient individual preference’ appear all too rarely in published guidelines, and doctors are in danger of projecting the pressure that they feel to conform onto their patients.

Many treatment decisions are a complex blend of objective medical evidence concerning risk, and need to take account of highly individual, subjective preferences, priorities and health beliefs. Respecting autonomy is one of the principal pillars of ethical practice, but all too often this is reduced to waiting for the patient to raise objections to the proposed treatment plan, or asking them to become an ‘expert’ in their own health, which can equate to expecting the patient to become the doctor.

True respect for autonomy is a highly active process. It involves creating an environment in which autonomy can flourish, and empowering the patient to make the right choices for their individual situation. It requires that the doctor knows and understands their patient, has a thorough grasp of what matters to them, and is able to distil the available medical evidence into an understandable, personalised format. It may involve supporting the patient when they choose to have treatments or investigations which the doctor would not choose for themselves, or giving licence to opt out of guidelines if they wish to, and turn down treatment without being made to feel like a naughty school child,

This respect cannot be confined to the consulting room, but needs to be enshrined in all aspects of health care – and health promotion in particular. Invitation leaflets for health screening should seek to enable informed choice rather than tell us what to do, and health awareness campaigns should avoid emotional manipulation and never, ever, look like this:

Cervical Screening Campaign Poster, Kirklees Feb 2012

If It’s Good Enough for Wiggo – Marginal Gains and Health

Sir Bradley Wiggins is a truly extraordinary athlete, but I am sure he would be the first to admit that his achievements in recent years are in large part due to the inspirational leadership of his fellow recently appointed Knight of the Realm, Sir David Brailsford. Sir David, in large part, puts his own success down to the holistic approach he has taken to improving performance – the concept of Marginal Gains. He explained the idea to the BBC during the high point of this summer of success:

“The whole principle came from the idea that if you broke down everything you could think of that goes into riding a bike, and then improved it by 1%, you will get a significant increase when you put them all together.”

Since the Olympics, people have begun to realise that there is no requirement within the concept of Marginal Gains to have spokes, wheels or a crash helmet, and disciplines unrelated to sport are using it to develop their thinking. Teachers are leading the way in the classroom and business bloggers have also latched on to the concept. Increasingly I have found myself talking about it in the consulting room, and wondering how doctors and their patients could learn from Sir David’s idea.

Health problems often leave people facing huge, seemingly insurmountable challenges. How can I get a good night’s sleep? What can I do about my weight? How do I stop my teenager shouting all the time? The success of medical treatments for simple, single cause health problems can often lead to both doctors and patients searching by default for that elusive single solution when faced with more complex issues – which leads to frustration and demoralisation when the problem remains unmoved by this approach.

Sleep difficulties are a good example. Losing sleep night after night can be so debilitating that the prospect of a single, simple solution is understandably very attractive – which must explain why the idea of a sleeping tablet is so seductive for both patients and doctors. The patient’s motivation to reach for a quick fix that might guarantee a full night’s sleep is perhaps more noble than the doctor’s temptation to resort to a tablet in order to bring a rapid conclusion to the consultation, but both are equally understandable when other solutions seem to offer less hope of a cure. The siren call of a sleeping tablet, however, is often less effective even in the short-term than we might expect, and brings with it the very real dangers of tolerance and dependence.

I might suggest that an insomniac tries a warm bath before going to bed, or keeps the room well ventilated at night, to which I will often receive the ‘done that, been there’ response, or the raised eyebrows of someone who really can’t see how that would help, and thinks I am trying to fob them off. The problem is that we often evaluate health solutions in a linear fashion – an approach that goes: ‘If this doesn’t work, try that’ as we work through one solution after another until we hit the jackpot. There are merits to this when it comes to some aspects of medicine – like using medication or arranging investigations where to try several things at once could be hazardous, but there are many health issues that could benefit from a more holistic way of thinking, both by doctors and patients.

There is nothing new to the concept of holistic health care, but this is often in the context of teaching doctors how to think holistically about their patients, as is enshrined in the GP curriculum for trainee GPs. What we may have neglected to do, however, is to find ways of helping patients how to think holistically about themselves. I wonder if there is an opportunity within health to use the concept of Marginal Gains, and its current high profile in the public consciousness due to the success of the British Cycling team, in order to encourage a different approach to solving health problems.

If having a hot bath before bed only gives a 1% extra chance of sleeping well, what would that mean if it was combined with a 1% improvement by having the right pillow? A similar gain might be achieved by a cup of hot chocolate, a well-ventilated bedroom, a ‘stimulation curfew’ after a certain time in the evening or going caffeine free. How many more marginal gains could we think of? Relaxation tapes, getting enough exercise, and eating earlier in the evening could all make their contribution. If they added together they could really start to make a difference – and even one good night’s sleep could reduce the dread of going to bed by a further 1%, bringing its own marginal gain in a virtuous cycle of improvement. Where we apply marginal gains we need to expect only marginal improvements – which will mean we will be less inclined to lose heart and give up when we don’t see instant results.

We could apply the same principles to many other health problems – where are the marginal gains for improving your relationship with your teenage children for instance? What small changes could start to add together in your life-long battle with your weight? What minor adjustments could you start to make to reduce the risk of burnout at work? It’s not glamorous, sexy medicine, but all too often the glamour in medicine turns out to be a mirage that lacks substance, or even does harm. In the gritty reality of the lives of real people maybe the hard, but achievable, graft of looking for marginal gains is a more honest and worthwhile approach to making a difference in health problems. And best of all, not only do you not need to become an Olympic athlete like Sir Bradley to apply start to think this way – you don’t even have to grow sideburns!

I’m sure I have more thinking to do on this one – more working it out in practice with my patients…expect more blogs to follow!

A Hiccup for the Health Check-Up

Scientific data can be a real headache for politicians, especially when it has an irritating propensity to directly contradict flagship Government policy.

This is exactly what happened last week, when a Cochrane review published the results of a meta-analysis on the efficacy of Health Check-Ups, which was widely reported by the BBC and others. The review looked at the effects of health screening in over 180 000 patients, and concluded that while those screened were more likely to be diagnosed with high blood pressure or raised cholesterol than those not offered the check-up, there was no difference in mortality, hospital admission or disability between the two groups. The review concludes:

From the evidence we’ve seen, inviting patients to general health checks is unlikely to be beneficial.

The problem for politicians is that this is undermines a key health policy from the Department of Health which involves inviting all people aged 40-73 to a health check to look for the risk of heart disease, stroke, type 2 diabetes and kidney disease. And this includes politicians of all the major parties – the policy was introduced by the Labour Government and has been continued by the Coalition.

What should we make of this? Aren’t we used to contradictory scientific headlines telling us that something is terribly good for us one week and causes cancer the next? Well, how hard we should listen depends on the quality and type of evidence before us. A small observational study is a very different piece of evidence to a large randomised trial, or a systematic review of all the evidence. I have borrowed an illustration from Margaret McCartney’s book The Patient Paradox which illustrates this well. It is a hierarchy of the quality of evidence, with the most reliable being at the top:

Cochrane reviews are not only at the top of this hierarchy as a systematic review, but they are also renowned in medicine as being among the most reliable, unbiased reviews that are conducted. They are important, and we should listen to them. Which is exactly what a Department of Health spokesman did not do in response to this important research. When questioned by the BBC, the response was to say:

By spotting people who are at risk of heart attacks, diabetes, stroke and kidney disease we can help prevent them.

The NHS Health Check programme is based on expert guidance. Everyone having a health check is offered tailored advice and support to manage or reduce their risk of developing serious health conditions.

So the power of a Cochrane review has been dismissed on the basis of expert evidence. When you look at the above hierarchy it is easy to see how ridiculous this is – it is like pretending that a pair of Jacks can beat a Royal Flush, it just does not work.

So where does this leave us? Well for the Government the situation is clear: Inviting large numbers of healthy people for routine health check-ups has no discernible benefit and the Department of Health programme should be reviewed. The main reason for this is that since it is of no discernible benefit, it is poor use of NHS funds. The checks themselves still need to be better evaluated, but they are not unreasonable – if you are going to have a check-up then to look at the 4 disease areas in question once every 5 years is probably the thing to do.

The organisations that really need to take note of this study (but they are unlikely to do so as they make too much money from health screening) are the private health providers like BUPA, which offer annual health checks that are far more wide-ranging than the NHS scheme – including many tests which are of zero value (such as measuring urate, the waste product implicated in gout which is uninterpretable in a person who does not suffer from gout) and others which are extremely controversial (such as prostate screening).

For individuals, however, we need an individual approach. When the Government first announced the proposal to invite people for check-ups most GPs felt mildly bemused – hadn’t we been doing this for years? You can always see your GP for a blood pressure or cholesterol check and the only thing that was different in the new policy was the invitations. There may be good reasons to assess your risk of conditions such as heart disease or diabetes, especially if there are particular concerns, such as a strong family history.

We must remember, however, that health check-ups are, by definition, performed on people with no symptoms. When we engage in health screening of any sort we cross a line that transforms us, temporarily, into a patient. We hope that this will be the briefest of forays into this alien world and we will soon return to our lives, unscathed, stamped with a clean bill of health and medical approval. We must always accept, however, that we may just remain a patient for longer than we have envisaged if a problem is picked up. This may have real benefits – such as avoiding a heart attack – but will also incur personal costs, including anxiety, more tests and the possibility of unnecessary treatment.

There is still a place for individual health check-ups, but these need to be tailored to individual risk, and also our personal views on how we like to deal with risk. We need to get away from the concept that every upright citizen “ought to have a health MOT”. We are not cars in need of a certificate of roadworthiness, and health screening is a complex issue: Its benefits are often far smaller than we first realise, and its potential for harm far greater than we like to admit.