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.