Is the NHS delivering too much of the wrong things?

More health care is not always better health care. Sometimes the NHS delivers services that people don’t want or need: the problem of overuse. This is part one in a series of three blogs – read the other two on underuse and misuse.

Overuse happens when health care is delivered even though the potential for harm outweighs the benefits. It’s bad for people receiving care because they get services which might make them worse – or at least waste their time and mean they are treated unnecessarily; it’s bad for the NHS because resources are used that could have been better spent elsewhere; and it’s bad for other people who need care because there’s less money around to pay for it. It’s also bad for other public services too, whose budgets are being cut while NHS spending is protected.

So, where might the NHS be delivering too much?

One example is prescribing antibiotics for people with coughs, colds and sore throats. While evidence tells us that antibiotics rarely make much difference for people with these conditions, GPs often prescribe them anyway – sometimes knowing that they won’t improve people’s health. This can cause unnecessary adverse drug reactions and might even contribute to growing antibiotic resistance. Between 1999 and 2011, the proportion of people given antibiotics for their coughs and colds rose by around 40 per cent. NICE estimates that around £4 million could be saved every year by prescribing less in this area.

Another example is diagnostic testing. Why are there more than 100-fold differences in the rate that GPs order some tests (for example, vitamin D tests) for their patients? For others (for example, blood glucose tests), why is it more like 1000-fold? While part of the answer is likely to be that some people aren’t getting the tests they need, or that patients’ preferences are different, the other part is that some tests are being carried out far too much. Overtesting can lead to overdiagnosis and overtreatment – each leading to harm to patients and wasted NHS resources.

A final example is some of the care delivered in acute hospitals. Take the intensity of hospital care at the end of people’s lives. While we know that many people want to die at home, poor access to community-based support (which can be cheaper than hospital care) often means that people spend time in hospital unnecessarily before they die. In one primary care trust area in 2007, 40 per cent of patients who died in hospital had no medical need to be there and nearly 25 per cent of them had been there for more than a month.

A range of elective treatments carried out in hospitals throughout people’s lives are obvious overuse candidates too – such as tonsillectomies in children, a procedure carried out at a rate ranging from 145 to 424 per 100,000 people aged 0-17, despite evidence that it is of low clinical value.

These are just a small number of examples to illustrate a much wider problem of overuse that often goes unnoticed across the NHS. It’s a problem that faces other health care systems across the world too, and its causes are complex. While overuse sometimes happens because health care professionals don’t know that alternatives (including doing nothing) could be better for patients, at other times it happens because the right alternatives might not be available at all. Overuse can also be driven by supply-induced demand (in other words, where the availability of services drives their use), along with payment systems that encourage more services to be delivered.

In cases where more than one option for a person’s treatment is available – which applies to much of the care delivered in the NHS – overuse happens as a result of the gaps between what patients want and what doctors think they want. When people are involved in decisions about their treatment, they often end up wanting less care, not more. Too often, decisions are made in a state of what Al Mulley and colleagues at Dartmouth would call ‘avoidable ignorance’: ignorance on behalf of patients about their condition, treatment options and potential outcomes, and ignorance on behalf of professionals about their patient’s preferences.

Tackling the problem of overuse requires action at all levels of the NHS – from changing the way that people are involved in decisions about their health and health care, to a new approach from national policy-makers towards NHS improvement. We set these changes out in our recent report, Better value in the NHS. The Academy of Medical Royal Colleges has also recently launched an initiative, Choosing Wisely, that aims to encourage clinicians and patients to work together to overcome avoidable ignorance and reduce unnecessary care.

Above all, we need to see the problem of overuse in the context of NHS services as common pool resources, where what we use effectively ends up taking away from others. In this way, overuse becomes a moral problem at odds with effective stewardship of limited resources.

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Comments

#544413 Paul Hellyer

agree, specially concerning the patient's role in decision making - but clinicians need time to discuss issues with patients and time is expensive. it's probably cheaper to write a prescription for antibiotics than spend 10 minutes explaining why they won't work.
Further why does the NHS spend millions on straightening children's teeth when there must be better ways to spend that money?

#544414 Kit Byatt
Consultant geriatrician
Wye Valley NHS Trust

Another area of overuse is when physicians see unselected medical admissions where the patient has a problem outside their specialty or knowledge. This often results in over-testing, and particularly so in older patients with multiple problems (some already known, some not), where one often find a sequence of testing, finding incidental abnormalities, following those up and/or treating them, encountering complications, more tests and/or treatments, etc.
Not infrequently, an experienced physician (& especially if a geriatrian!) can: a] see what's actually worth following up, and b] establish the patient's preferences re interventions & goals.
Trouble is, with many geriatrian posts (both training and career grade) unfilled nationally, and burgeoning areas where we might help (orthogeriatrics, frail admissions, pre/perioperative work, community admissions avoidance, deprescribing, stroke medicine, delirium/dementia, etc...!), we're being increasingly stretched. Much of our work can be enhanced with nurse practitioners, etc, but my experience is that non-doctors are reluctant to commit to a diagnosis judgements upon which everything else depends. This, it seems to me, is one of the key roles of the geriatrician - whether in primary or secondary care.
Shame the training numbers (and the appointment to them) are both less than ideal!

#544415 Nick Mann
GP
Well St Surgery

Most of this has already been incorporated into practice, and certainly into the mindset of doctors. Debate about overuse of medicine and treatment must be in context of the problem we really face in the NHS now: there is not adequate funding or resource to provide what is actually necessary. Variation in testing and treatment rates also needs appropriate context to have any meaning. Come do my job before you tell me I'm wasting precious NHS resources and harming rather than benefiting patients.

#544417 Clive Siddall
Retired
Na

I am convinced that there is a huge issue with over diagnosis by GP's . I do not know the cause but it seems that any minor ailment reported by a patient is analysed through a huge excess of testing and further testing . Ironically the drugs that are not critical are prescribed like sweets whereas the ones that really matter take an eternity to. E described . I make these points mainly as a result of seeing the way my father has been over treated by the NHS . He is 89 and has quite a few drugs which in my opinion are irrelevant . He has Alzheimer's and getting the prescriptions for that have conversely been very difficult to get.

#544421 Matthew Shaw
Gp
Brookside Group Practice

Unrealistic expectations of patients & relatives, + breakdown in trust + fear of complaints by clinicians + a health service free at point of access + demands armed with patient charters and "rights " without responsibilities.
Do the math... Needs more than a discussion amongst a few doctors.

#544422 Alan 'Brand' Wi...
Brand Developer
Brandopia

As long as the medical profession - NHS or Private - are paid/rewarded for treating 'sickness', then you will continue to get poor results/overuse of drugs/costs out of control. A new paradigm is needed, where medics are only paid/rewarded for keeping people 'well' or 'disease-free'. Overnight you'll start seeing 24/7 services, massive reduction in the use and costs of drugs and an explosion of preventative health care.

#544423 Diana Lauder
Retired nursing sister

I wonder how much the advent and promotion of "pre" diseases are causing great unnecessary anxiety amongst patients and whether or not their diagnosis is directly or indirectly the result of interference/ direction from pharmaceutical industries. Who do we trust now?

#544428 Chris Craig
Community Paediatric Nurse
Southern Health NHS Foundation Trust

I feel that some people using NHS services are expecting something or someone to sort their problem, so they don't have to. A gastric band for over eating and lack of exercise, a pill to stop smoking, CAMHS for their child's poor behaviour. We are enabling rather than empowering service users, which requires more resources than if people feel that their good health is their responsibility.

#544429 PhilT

The large expenditure on Vitamin D supplements by the NHS merits investigation. Could people get them cheaper retail. Is incorporation into food better. Is public health advice about sun exposure the root cause. Do vitamin D supplements have positive health outcomes. etc.

I would start by taking initially 20% of the Vit D expenditure out of the budget and challenge the professionals to live within it.

#544430 Riza Ibrahim
Consultant Vascular Surgeon
Pennine Acute Hospitals NHS Trust

I am not sure i understand Alan's comment about HCPs not being paid to 'treat sickness', but being rewarded for 'keeping people disease free or well'!!
Surely, you do not expect health care proffesionals to picket fast food joints and places that sell cigarettes & alcohol! or indeed expect them to run gyms?

#544432 Frank swinton
Consultant anaesthetist
Airedale NHS FT

Great blog. All this extra unnecessary stuff is harmful to the environment too. Let's have some rationalisation and a grown up conversation about expectations vs. costs.

#544440 alison salmon
district nurse
health

the waste and cost of prescriptions could be reduced by charging a small amount to everyone,. If it was nominal amount and charged across the board such as 50p an item, people would treat their ordering with greater care and be less wasteful, it would also create a fairer system.

#544441 Joanna S Woodger
Consultant
CPFT

I agree with above, however the way out may be not that easily accepted by public. Stop complaints culture,start trusting that health professionals aspire to deliver excellent care, deliver truely holistic service ( including bringing back together mental and physical health ), use common sense and expect self-responsibility. We need to start conversation about realistic expectations and protecting the NHS from being abused.

#544442 Dr Roopa Mulik
Consultant Paediatrician
Heart of England NHS Foundation Trust, Birmingham

I fully agree with the comment here by a GP about; Unrealistic expectations of patients & relatives, + breakdown in trust + fear of complaints by clinicians + a health service free at point of access + demands armed with patient charters and "rights " without responsibilities.
Do the math... Needs more than a discussion amongst a few doctors.
In my field of work normal healthy babies who cry normally whose mothers are finding it difficult to cope, get labelled as 'Lactose Intolerance' or 'Milk Intolerance' of some sort and/or G/O Reflux and are prescribed a variety of special baby milks and reflux medications, they get referred to Paediatric Clinics where it is hard to convince the mothers that the baby is normal and things will settle without any medical intervention. I, one of the most experienced doctors, spend 80% of my work time doing clinics looking after ‘worried wells’ trying to manage over-diagnosis in Primary Care at the same time juniors are doing over-investigations and over-diagnosis on the acute front. This practice is so embedded in NHS culture that it is hard to convince colleagues that this seems wrong way of working.
Once you do the tests and scans for trivial symptoms without clinical need you give impression to parent that their child needed scan/tests for this symptom; this creates unrealistic expectations amongst other parents and the cycle continues. Doing tests in NHS is much easier than not doing as over-investigations is so common that it has become the norm! The reasons are complex and solution is not simple but the profession has some responsibility towards it too.

#544446 Nick

I agree that this is complex. I'd suggest that a further reason is the prevelance of a market lens, or market thinking, both within the NHS and wider society. Once we speak in terms of supply, demand, products, productivity, and thinking of everything in monetary value it is an easy step for any human discomfort becoming a sales opportunity for someone, even if the buyers and sellers are not in a simple customer relationship. It means more intervention, more treatment. The answer is not more market. For example, a 50p universal prescription charge might make a few patients think twice, but it would also push patients a bit further towards being 'consumers' of healthcare. You probably all know the example of a kindergarten which started fining parents for late arrival, and late arrivals went up, because it just became a transaction, rather than a moral commitment.

#544463 Stuart
clinical manager

I work in Mental Health and the number of referrals from GP's for 'mental health input' is incredible. There tends to be no consideration or understanding of what they are referring for or what benefit this may have on the individual.
When challenged the response is invariable I am the Doctor and therefore you will see. This results in allocation and assessment for the individual of which currently about 27% require no further input and 18% are referred to local voluntary agencies or support. This 45% of referrals which do not require NHS support could and should have been directed at the Primary Care level.
I am aware of the time pressures on GP's to see a large number of individuals in a short space of time however the result is a label of mental health problems for individuals that just need local support.
There is clearly a role for further training for GP colleagues in Mental Health and also the impact that a Mental Health referral and potentially a diagnosis can and does have on an individual's life and family.

#544561 Dr Kadiyali M S...
Retired GP
NHS

We cannot blame patients but blame the system. GPs were doing their job and managing the primary care in 1980s. In 1990s, we were forced directly or indirectly to audit and so the so called "Evidence based medicine" was born. I blame the system because you can commit blunders but shield yourself from prosecution claiming the evidence based medicine advised treatment. After all its us who write the notes, so wrong statements, false information written in the notes is very common.
The problem is not complex but we must standardise primary care physicians and emergency care providers. Once they make an error, the damage is done and so it will be difficult for other doctors to clean the mess.
I raised concern in 2003 and produced documents to prove using nurses as the gatekeepers is not in the interest of our profession or the humanity. Now I do not know weather to cry or laugh at all the disasters that has brought us shame.

#544563 Dr Kadiyali M S...
Retired GP
NHS

By the way, I have not given up the fight and am soon releasing a book to help people know what their doctors must do. I have also created an app to share information, so that the patients will know what to expect from their doctor before speaking or contacting. The information I share is one that I have used and shared with my juniors for almost 30 years (so tested and proved to be safe).

I hope education is the answer to reduce over use and reduce wasted consultation.

#544572 cheryl c
nurse
NHS

Recently I have been drawn into a poor clinical protocol for latent TB, having been determined 45 years ago to be free and immune so not requiring BCG vaccination. Blood tests are inconclusive so I need to see a respiratory nurse ( I have no respiratory problems ) who will advise me it could come back, although highest risk is 5 years after exposure (long since passed) so do I want lots of antibiotics in case? In the meantime I cannot donate blood until a test determines I am all clear - it will not.
Whilst this may be a useful protocol for those with a high risk of recent exposure it has been handled without a lack of judgement and clinical reasoning and risk management. The consequences of agreeing to the protocol were not explained, nor was the likelihood of equivocal results (high) and the waste of resources, manpower and my time away from clinical work. This seems to me a classic example of unthinking wastefulness and even worse reducing the already pressured blood donation service and further misuse of exposure to antibiotics.
Now I have to find the energy and time to challenge this so improvements can be made and wastefulness and adverse consequences for others can be recognised. What happened to clinical governance?

#544586 Julie Ann Racino
Author: Public Administrtion and Disability (2014)
Community and Policy Studies

The mental health field in Europe and the US has grown exceedingly large with great concerns about those involved in population health. The figures on involuntary care and institutional care are still staggering, and are often presented without any plan for decreasing these numbers (See, UN Convention on the Rights of Persons with Disabilties, 2006 and work on Principles in Mental Health from 1999).

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