The over-medicalisation of illness in the NHS is down to patients acting like customers
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Version 0 of 1. The most upsetting and haunting of the things I found when I was sorting through my late mother’s things was a handwritten list in a notebook by the chair where she always sat. Every day for a short while, before she was admitted to hospital and diagnosed with secondary renal cancer of the bone, she’d been jotting down the details of the painkillers she was taking and the time at which she was taking them, in a very shaky hand. These weren’t strong, addictive painkillers. They were paracetamol and ibuprofen. It was awful to imagine her sitting there, her face twisted with pain, watching the clock until it was time to get a smidgeon of relief from agony. Or maybe not. Recent studies suggest that paracetamol simply doesn’t help lower-back pain, which is what my mother complained of. Not that my mother would have believed such heresy. I hadn’t understood quite how much pain she had been in, and I don’t think her doctor did, either. For 40 years, since early middle-age, my mother had been answering the question “how are you?” with the reply: “Oh, all aches and pains.” This was followed by a short silence, by way of invitation for me to ask her to offer further detail on the exact nature of the aches and pains, the inefficacy of the tablets she was taking, and how she was going to have to go back to the doctor. She was the mother who cried wolf. But still she retained her faith in medicine through all these decades of frustration and dissatisfaction with it. That’s what the list was all about – her fear of and respect for this powerful, almost magical, yet capricious intervention. Doctors and medicines – my mother’s belief was that these and only these could ever have a positive impact on health. I tried a number of times over a number of decades to suggest to my mother that her pains would be treated better with some exercise than with pills. A yoga class maybe, a bit more walking, a swim now and then. Maybe fewer starchy and sugary foods? Maybe she was carrying a bit too much weight? But, in truth, I didn’t push too hard on this stuff, because it made her furious. Mum was implacable in her belief that the fad for diet and exercise was a con that only gullible, self-righteous fools like her daughter were pretentious enough to believe in. Given the choice between a stroll round the block and a bottle labelled “snake oil”, my mother would pick up one of the wide selection of little white plastic measuring spoons she kept in the kitchen drawer. Related: Doctors to withhold treatments in campaign against 'too much medicine' So she would be very suspicious of the news that the Academy of Medical Royal Colleges wants to crack down on what it calls the “over-medicalisation” of illness. The plan is to make a list of 100 tests and treatments for which there is only minimal evidence of minor benefit, and advise doctors to think twice before prescribing them. I think that sounds like a tremendously useful list. But I’m the type who takes friends off the Christmas card list for saying that their cold’s really bad and they’re going to the doctor for some antibiotics. “You!” I always think. “YOU have broken antibiotics.” But my mum would not be alone. Already, there is talk of “rationing” and of “withholding treatments”, as if supporting the ability of NHS staff to make decisions based on expertise and science, and not on what their patients read on the internet, is tantamount to recruiting some kind of sinister enemy within. But maybe it’s this putative list of 100 pointless interventions that needs to go on the internet, so that patients can turn up having read about that. It makes me despair, this kind of knee-jerk assumption that every suggestion that might make the NHS more efficient is an attack on it. On the contrary, the loser in a successful drive against over-prescription would be the private drug company that’s selling useless pills or testing equipment at a profit. Market attitudes are what sell us things we don’t really need, and the award-winning New Yorker writer, Atul Gawande, confirms that the problem of over-medicalisation is bigger in the private systems of the US than it is here. He quotes research that found up to 42% of Medicare patients had received at least one of 26 absolutely useless tests and treatments in one year. The researchers called it “low-value care”. Gawande suggests that it should be called “no-value care”. At the moment, NHS hospitals are paid for giving treatment, not for refusing it. Likewise, doctors are incentivised to prescribe certain drugs as often as possible, when lifestyle changes would serve patients and the NHS much better in the long term. One problem, however, is that my mum would have enjoyed being told to exercise and eat better by a doctor every bit as much as she loved being told the same thing by me. It’s not what patients want to hear. They want to hear that there’s a pill or a test or an operation that can help. Doctors are human, and studies have shown that the better they know a patient the more likely that are to say things that make the patient feel better, and the less likely they are to say things that will challenge them, or that might feel nagging or critical to a person already in distress. It’s important to recognise that doctors can and do feel pressured into an attitude – caring and empathetic as it may be – that is similar to the market’s “customer is always right” ethos. People bang on about how the marketisation of the NHS must be resisted. But the facts on the ground are that it’s hard to tell patients that they’re wrong – wrong to believe that doctors can always help them more with their ailments than they can help themselves, and wrong to believe that there’s a pill for every ill. Maybe, we, the patients, are behaving a bit too much like customers, and helping to marketise the NHS in our own small way too. |