Intended for healthcare professionals

Opinion Dissecting Health

Scarlett McNally: Patient empowerment and retention of doctors is vital for the UK economy

BMJ 2023; 381 doi: (Published 24 May 2023) Cite this as: BMJ 2023;381:p1134
  1. Scarlett McNally, professor
  1. Eastbourne
  1. scarlettmcnally{at}
    Follow Scarlett on Twitter @scarlettmcnally

As a medical student in the 1980s, I was told that the reason there were no initiatives to limit smoking was that lung cancer wasn’t treatable; smokers paid taxes all their lives and died younger, often without collecting their pensions. There was a financial disincentive for governments to take measures to limit smoking. I saw the damage to patients in hospitals first hand. Cynically, it appeared that measures to ban smoking came in only when expensive treatments for lung cancer became available.

There are now over 1.5 million attendances for chemotherapy in the UK each year.1 Cancer is no longer a binary live or die option, but a long term condition. Nearly five years since my own myeloma diagnosis, I still attend for regular chemotherapy or immunotherapy—for a condition I would have died from if not for medical advances. But consider the years of prophylactic antibiotics, steroids, appointments, and investigations—all multiplied by hundreds of thousands of people in treatment.

Clearly, we should invest in prevention. We can’t afford not to, especially with increased multimorbidity. Some 40% of cancer is preventable.2 Dementia costs the UK economy £34.7bn a year, but up to 40% of dementia could be preventable.34 Ill health among working age people costs the UK economy an estimated £100bn in benefit payments, healthcare, and lost taxation.5

Most ill health is preventable.67 The leading risk factors of disability adjusted life years are smoking, poor nutrition, physical inactivity, pollution, and alcohol.8 Poverty and poor education contribute to ill health through these and other means.

We need action at all levels. Policy and environmental changes supported by funding are needed to allow physical activity, better nutrition, and reduced pollution. Patients want to be involved and to understand their care options as a Patient Information Forum report shows.9 Patient empowerment means encouraging them to ask about “BRAN”—the benefits, risks, alternatives, and the doing nothing option—this is fundamental to shared decision making.10 It also means helping patients and their communities to improve their general health. The UK chief medical officers’ new report11 discusses how to implement their physical activity recommendations—the same 150 minutes a week that we have known about since 2004 and that 36.8% of adults12 in higher income countries do not achieve.

Two unspoken concepts must be acknowledged. Firstly, people have cognitive dissonance: they often know what is right in principle but don’t do it. Surveys also show that patients’ fear of adverse events and worsening symptoms remains a significant barrier to behavioural change, for example those with long term conditions may be concerned about the risks of physical activity.13 Secondly, doctors are experts at managing risk and complexity with patients but other staff are often rightly risk averse, leading to patient passivity and over-investigation. Some 21% of adults in the UK are living with disability and 62% of those aged over 65 have multiple comorbidities.14 We need doctors, steeped in years of education and experience, to individualise care options with complex patients, including prevention, shared decision making, and avoidance of overmedicalisation.

Every doctor must be nurtured if we’re to retain them in the workforce and within their teams, now and for the future. This means adapting work patterns, conditions, expectations, and postgraduate training programmes, with pay restoration, functioning IT, administrative support, and better team working.

Empowering patients and valuing doctors can reduce costly ill health and wasteful healthcare. This would benefit citizens and the UK economy.