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.

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)