Keep politics out of healthcare

Tony Blair’s encounter with Sharron Storer outside the Queen Elizabeth Hospital in Birmingham in the first week of the election campaign was richly symbolic.

He was visiting a hospital as a photo-opportunity to link New Labour with the caring – and modernising – NHS, a key election theme. She was there to complain about the poor treatment received at the hospital by her husband, who has cancer.

While New Labour has singled out health as a crucial area through which the new political elite can establish its authority in society, its political initiatives in the NHS are likely to make existing problems of poor standards even worse.

There is a basic contradiction at the heart of Blair’s health policy. New Labour wants to use the issue of health to display its concern for the welfare of its citizens and enhance its authority in society, but most citizens are only interested in getting decent health care when they need it.

Here Sharron Storer’s experience strikes a chord with anybody who has waited for hours, if not days, in a hospital casualty, with all those still waiting for a hospital appointment or for admission for surgery, not to mention patients languishing in dirty wards tended by overworked and demoralised staff.

The government wants to take advantage of recent survey findings: the public still puts the highest levels of trust in doctors and nurses (and the lowest in politicians and journalists). Unfortunately, government initiatives in the NHS are more likely to weaken trust and undermine public confidence in health service professionals.

Feeling isolated and insecure in relation to society, government ministers believe that they can reflect popular concerns about health and use health-related projects to establish points of contact with the public. The trouble is that such initiatives tend both to divert scarce resources and to get in the way of the real work of doctors and nurses – treating the sick.

Take NHS Direct, one of the government’s favourite initiatives – its headquarters were chosen by Tony Blair’s team for a photo-opportunity early in the election campaign. As NHS Direct’s breathless prospectus indicates, ‘in less than three years, it has grown from three relatively small pilot schemes to become one of the largest providers of telephone-based healthcare in the world’ (1).

This 24-hour helpline expresses the aspiration of New Labour politicians to establish ‘one-to-one’ relations with members of the public – and they particularly value the therapeutic content of relations established around issues of health.

This is how the government explains the rationale for its 24-hour health phoneline: ‘NHS Direct is a response to the desire for patient empowerment. But it also recognises that many people need help to make the right decisions. Furthermore it recognises that people may need the reassurance of being able to speak to a health professional at any time of the day or night.’

I do not recall any popular movement among patients demanding NHS Direct or anything like it. The notion that the patient is ’empowered’ by NHS Direct is immediately contradicted by the way this patient is reduced to the role of a helpless child who needs parental guidance and reassurance. It is the government that needs NHS Direct and the relations of dependence and subservience with the public that it fosters.

Sponsors of NHS Direct claimed that it would reduce demand on the NHS by encouraging people to look after themselves and by deterring people from going to their GP or local Accident and Emergency department when this was unnecessary. But a survey of the impact of NHS Direct in its first year concluded that it ‘did not reduce pressure on NHS immediate care services’, though it may have restrained increasing demand on GPs’ out of hours services (2).

Thus despite drawing hundreds of the more experienced and most sorely needed nursing staff out of the wards and into the call centres – at a cost of £80million a year – NHS Direct has had no compensatory beneficial effect on the demand for services. Despite the government’s commitment to ‘evidence-based policy’, these negative conclusions from its own commissioned research did nothing to deter the expansion of NHS Direct.

Though NHS Direct has only been available in North London for the past six months, I have already seen several patients who have come into the surgery – as it turned out, unnecessarily – after phoning the helpline. There have been numerous reports of patients receiving inappropriate, even dangerous, advice. The ready availability of information and advice about health matters itself tends to reinforce prevailing anxieties about health, and hence to encourage the relentless increase in demand for ‘face-to-face’, rather than ‘one-to-one’, medical reassurance.

NHS Direct is the prototype of New Labour’s health initiatives: a service that answers the government’s need for mechanisms that promise to close the gap between the state and the people. A service that nobody wanted inevitably fosters new needs, in a society of increasingly atomised individuals rendered chronically anxious about their health by a stream of government-sponsored scare-mongering in the guise of health promotion.

The list of similar initiatives includes the establishment of ‘walk-in’ GP surgeries, the drive to reorganise primary care to guarantee an appointment with a GP within 48 hours and the proclamation of arbitrary waiting list targets.

This approach to health policy reached its nadir in the establishment, in the aftermath of the Alder Hey scandal, of the ‘retained organs’ commission, which is currently engaged on a trawl through the pathology labs of the nation with a view to returning diverse body parts to the relatives of the deceased (3). In its desperation to connect, the government is ready to promote and exploit the most mawkish aspects of popular sentiment, whatever the cost to the health service in terms of resources, morale or prospects for medical research.

The government has selected cancer and heart disease as priority areas for increased investment to guarantee early assessment and treatment. Because these diseases provoke strong fears, they are an obvious choice for politicians keen to make an emotional impact on the public.

It is true that these conditions are responsible for a substantial proportion of all deaths in Britain. However, the vast majority of these deaths are in elderly people – you have to die of something – in whom the scope for medical treatment is often small. It is also true that both cancer and heart disease sometimes strike younger people, but unfortunately the benefits of early detection and treatment are by no means clearly proven.

To illustrate these, rather contentious, points, let me give two examples of high-profile government initiatives, one in relation to cancer (screening for carcinoma of the prostate), the other in relation to coronary heart disease (chest pain clinics).

In March 2001, health secretary Alan Milburn announced that the Prostate Specific Antigen (PSA) test is to be made available on the NHS (4). The problems begin from the fact that the PSA test yields high levels of both false positive and false negative results. Depending on the cut-off level used, up to two thirds of men who have raised PSA levels do not have prostate cancer. On the other hand, some men who have prostate cancer do not have raised PSA levels.

However, once somebody has had a test yielding a high result, this leads inexorably to more invasive investigations, such as a transrectal needle biopsy, which also carries risks of haemorrhage and infection. At present only 30 to 40 percent of men having a biopsy for raised PSA are found to be positive for cancer, a proportion that is likely to decline as more men demand PSA tests.

A positive diagnosis of prostate cancer leads to further problems. There is a wide variation in the rate at which this poorly understood tumour develops. In some men, it grows rapidly, spreads to the bones, and causes death within a few years. More commonly, it grows slowly and never causes wider problems – most patients die of other causes.

It is not at present possible to differentiate between these two extremes at an early stage, making it difficult to decide on the best form of treatment. Various treatments are available – including surgery, radiotherapy and hormone therapy – but the evidence for the superiority of any particular treatment is poor. All carry significant risks, notably of impotence and incontinence.

Now that New Labour has made the promotion of prostate awareness into a political principle (in response, William Hague is demanding universal screening), and the cause has been taken up by the mainstream press, a rising demand for PSA testing is already evident.

The inevitable result of greater public awareness of prostate cancer will be that large numbers of men will be subjected to investigations (and even treatment) that will be of no benefit to them, while causing considerable adverse effects. Furthermore, this enhanced awareness will not benefit men with prostate cancer: indeed it will divert resources both from their treatment and from the research necessary to discover more effective screening tests and treatments.

One of the commonest symptoms that is presented in general practice is that of pain in the chest. When this has a typical tight and gripping character, develops in the course of exertion and resolves on resting, in a person over the age of 50, this suggests coronary heart disease. When, as is much more common, the pain is sharp, localised to one side of the chest (usually the left), is unrelated to exertion and appears in an otherwise fit young man, this is highly unlikely to have a cardiac origin. Further discussion usually reveals family or work-related anxieties. In the past, a GP would usually refer the former for further investigation and reassure the latter.

No longer. Now the government is encouraging the establishment of ‘chest pain’ clinics, to which both the middle-aged high-risk patient and the young ‘worried-well’ patient will inevitably be referred. Once these clinics are established, patients will be entitled to demand the reassurance of expert assessment and investigation, even when the chances of heart disease are minimal.

The consequences can be easily anticipated. First, the clinics will be swamped by the worried well, whose inclination to medicalise their problems will be reinforced, thus putting off any attempt to get to grips with the underlying problems. Second, the really ill will suffer, as resources are devoted to managing the anxieties generated by government-promoted awareness of the significance of chest pain.

New Labour’s focus on health may help to ensure a second term for Tony Blair. Whether it will succeed in helping to bolster the legitimacy of the new political elite which New Labour represents remains uncertain. Its negative consequences for the health of the nation are, unfortunately, already all readily apparent.

Dr Michael Fitzpatrick is the author of MMR and Autism, Routledge, 2004 (buy this book from Amazon (UK) or Amazon (USA)); and The Tyranny of Health: Doctors and the Regulation of Lifestyle, Routledge, 2000 (buy this book from Amazon UK or Amazon USA). He is also a contributor to Alternative Medicine: Should We Swallow It? Hodder Murray, 2002 (buy this book from Amazon (UK) or Amazon (USA)).

Read on:

(1) ‘NHS Direct: A New Gateway to Healthcare’, 2001. Available at www.nhsdirect.nhs.uk

(2) British Medical Journal, 15 July 2000

(3) See spiked-issue: Body parts

(4) See Why ‘awareness’ is bad for your health, by Dr Michael Fitzpatrick