Is the NHS delivering too much of the wrong things?

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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.

Comments

Paul Hellyer

Comment date
12 August 2015
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?

Kit Byatt

Position
Consultant geriatrician,
Organisation
Wye Valley NHS Trust
Comment date
12 August 2015
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!

Nick Mann

Position
GP,
Organisation
Well St Surgery
Comment date
12 August 2015
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.

Clive Siddall

Position
Retired,
Organisation
Na
Comment date
12 August 2015
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.

Matthew Shaw

Position
Gp,
Organisation
Brookside Group Practice
Comment date
13 August 2015
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.

Alan 'Brand' W…

Position
Brand Developer,
Organisation
Brandopia
Comment date
13 August 2015
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.

Diana Lauder

Position
Retired nursing sister,
Comment date
14 August 2015
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?

Chris Craig

Position
Community Paediatric Nurse,
Organisation
Southern Health NHS Foundation Trust
Comment date
14 August 2015
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.

PhilT

Comment date
14 August 2015
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.

Riza Ibrahim

Position
Consultant Vascular Surgeon,
Organisation
Pennine Acute Hospitals NHS Trust
Comment date
15 August 2015
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?

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