Should Policy Makers Tell GPs How Often to Diagnose?

I’m sure NHS England were surprised by the response to their plans to pay GPs £55 every time they diagnosed dementia. What started as a seemingly simple idea to help the Government hit their diagnosis target before the election caused such a furore that Simon Stevens declared the end of the policy before it had really begun, making it clear that it would end at the end of March.

What was striking about the reaction was not the objection among GPs – policy makers are used to that and well accustomed to ignoring it – but the strength of feeling among the public. I’m sure this is what made the difference – no politician wants to lose in the arena of public opinion. It’s not hard to see how this happened. There was something innately wrong about paying GPs to diagnose; no in-depth analysis was needed, no exploration of the evidence – it was just so clearly a bad idea and both doctors and patients were alarmed at want it meant for the doctor-patient relationship.

What continues to concern me, though, is that policy-makers still think they know best when it comes to how many patients GPs should diagnose with a variety of conditions – from heart disease to asthma, diabetes and even depression – and have an even more powerful mechanism for enforcing this, which is to put pressure on practices with low diagnosis rates through naming and shaming, and the threat of inspection. A practice may have the moral courage to resist a financial bribe, but what about if the reputation of your practice is at stake?

I have written in the British Medical Journal about this, published this week, and this is a toll-free link if you are interested. What is crucial is that at the moment of diagnosis there should be nothing in the mind of the GP other than what is best for the patient – it is fundamental to the doctor-patient relationship and something well worth shouting about.

A Message To Our Patients

Last week the Care Quality Commission (CQC) published data on every GP practice, placing each practice in one of 6 bands in order to prioritise them for inspection. The CQC has been very keen to point out that the way it has banded practices is not a judgement on them, as this can only come when the full inspection is completed. Despite this, the newspaper headlines described large numbers of ‘failing practices’ which will have inevitably worried patients; the fact that the CQC used the word ‘risk’ in its reports is a shame, as it has made it more likely that patients will be concerned.

At Binscombe we have been given a band 2 out of 6, which has been hard to take, not because we are worried about an early inspection – we are happy to be inspected at any time – but because the banding does feel like a judgement, and we believe that we give far better care than that. The banding may also have caused anxiety for our patients, and this too is a concern for us.

The CQC reports look at 38 individual pieces of data, from how often the patients at a practice attend A&E, to how our patients rate the practice in the annual GP survey, to how many patients with high blood pressure achieve a certain blood pressure target. There are many other pieces of data they could have chosen, and we had no idea until last week which they would choose, but these are the ones they have picked. Each indicator has an expected value the practice is meant to have achieved, and if the practice is significantly below that value then this will indicate a ‘risk’, with the number of ‘risks’ determining which band the practice ends up in.

There are several indicators that come from the GP annual survey on patient care where we have scored exceptionally well. For instance, when it comes to the percentage of patients who said that the GP they saw was ‘good or very good at treating them with care and concern’ we were expected to achieve 85%, when in fact 97% of our patients felt able to say this. We are incredibly proud of this. We don’t get it right every time, but we always try hard to listen to our patients, to share their concerns and involve them in all decisions about their care.

Where the practice has been criticised in the report mostly relates to indicators that are more about monitoring than listening. These are:

  • The number of patients with diabetes whose blood pressure has achieved a target of 140/80
  • The number of patients with diabetes who have had a routine foot examination in the previous 12 months
  • The number of patients with diabetes who have had their urine tested for protein in the previous 12 months
  • The number of patients with serious mental health problems who have a record in their notes of alcohol consumption in the previous 12 months

And one area to do with the layout of our practice waiting area:

  • The number of respondents in the GP survey who said they could not be overheard in the waiting area.

These are not unimportant, but there is always a tension in a GP consultation between addressing the concerns a patient wants to talk about and the requirements to monitor and treat things like blood pressure. In an ideal world we would always do both, but too much attention to the latter can make the patient feel like they are not being listened to and that the doctor’s agenda is more important than their own.

Last April, Jeremy Hunt said he wanted to end the ‘tick-box’ culture in medicine that too often distracted GPs from spending quality time with their patients, and this is something we have welcomed. While we will address the concerns of the CQC, we will never want the patient to take second stage.

The issue of being overheard in the waiting area is a difficult one. We would certainly like to have an area where patients could talk in the confidence that they cannot be overheard, and we take confidentiality very seriously, but we are constrained by the practical reality of our building and the waiting area. It is not easy to see how we could put up a screen between reception and the waiting area, but we will certainly be looking at any possible solutions to this problem.

We take the CQC report very seriously, and we will be working to address the issues raised within it. We know we are not perfect and we are always looking to improve the care we provide for our patients. When Chris Jagger was at the practice he always used to say that our patients are our greatest asset; this is as true now as it ever was, and we are very grateful for the support we receive from Binscombe patients.

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.