Feature Overtreatment

Is the USA’s problem ours too?

BMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e6617 (Published 03 October 2012) Cite this as: BMJ 2012;345:e6617
  1. Margaret McCartney, general practitioner
  1. 1Glasgow, UK
  1. margaret@margaretmccartney.com

The United Kingdom is fortunate that it is insulated against some of the needless overtesting, overtreating, and overdiagnosing that doctors in the United States are rising up against. Instead, we have the National Institute for Health and Clinical Excellence (NICE), which offers evidence based appraisals of healthcare interventions and screening and which protects against treatments of little or no efficacy being offered on the NHS. We also have the UK National Screening Committee, which provides critical reviews and recommendations of what screening is effective and useful.

Does this mean that we can relax? Unfortunately not. The general practice contract has improved the quantification of what we do, but the price of this is that more patients are exposed to guidelines rich in pharmaceutical recommendations. Some may be beneficial. However, most lack guidance about when prescribing should end or is no longer likely to be useful; we lack data about the risks of the polypharmacy that the contract generates. It is common for patients to be taking 10 or more medications; yet such patients are rarely seen in randomised controlled trials. Faced with the contract, GPs are made to ask themselves why a patient is not taking a drug, rather than why they should be.

A long campaign for fairer, better information on NHS screening—which was supported by one of the instigators of breast screening in the UK, Professor Michael Baum—looks like it may have, at least in part, succeeded. The current review of information given about screening tests in the UK is likely to recommend balanced information on the pros and cons of screening and promote informed choice.1 There is no doubt that screening causes overdiagnosis and overtreatment. However, private screening clinics, of which there are many, thrive.

Similar problems are created by non-evidenced awareness campaigns. For example, the UK government’s recent “Three week cough campaign” to promote awareness of lung cancer increased the number of chest x rays performed but did not significantly increase diagnoses of lung cancer.2 Charities also use awareness campaigns, but the benefits of earlier diagnosis are rarely proved and they risk investigating people who are unlikely to benefit.

These campaigns are often pivotal to publicity by patient groups and charities. However, financial relations between these groups and the drug industry—with its agendas for the uptake of new interventions and its PR expertise—are often unclear. And despite the continuing problems of opaque data from clinical trials,3 earlier this year doctors were told not to “accept the negative myths about cooperating with industry” in guidance supported by numerous colleges, medical journals, the BMA, and the Association of the British Pharmaceutical Industry.4

Shopping last month, I was handed leaflets from a stall demanding “awareness” about restless legs, suggesting I could get treatment from my GP. The same week a drug representative tried to gain access to my practice to “educate” me on treatments. We can hardly avoid harm when we allow this to perpetuate.

But politics threatens most. The coalition government intends to begin “value based pricing” in 2014; this will mean that government rather than NICE will decide which treatments to fund.5 Will this result in political whim, rather than evidence based, decision making? The Health and Social Care Act has given permission for the dissolution of the NHS into a mere brand, and with competition companies who are likely to fragment care despite evidence that continuity results in less intervention and better satisfaction.6 7 Our iatrogenic harms may be slightly less obvious than those in the US, but they are politically engrained.

Notes

Cite this as: BMJ 2012;345:e6617

Footnotes

  • doi:10.1136/bmj.e6230
  • Competing interests: The author has completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References