The dangers of ‘pay scales’ for doctors

The UK National Institute for Health and Care Excellence (NICE) has proposed that family doctors should be paid extra to tackle patients’ weight problems rather than simply monitoring them. Under the proposal, anyone with a body mass index (BMI) of over 25 – that is, above ‘normal’ weight – would have their weight discussed with them and then appropriate weight-management steps would be taken, including being referred to weight-loss groups and diet clubs. Those consulting-room scales will soon go ‘kerching!’ when we step on them, if NICE has its way.

The proposal sounds bonkers. First, there is the assumption that anyone falling into the ‘overweight’ or ‘obese’ categories is either ill or on the way to being ill. That’s two-thirds of the population – a bizarre assessment, given that people are actually living longer than ever before. In fact, health risks are lowest among the mildly overweight, while the mildly obese have little difference in health outcomes from people of ‘normal’ weight. Pathologising ordinary chubbiness is simply making more work for the NHS unnecessarily.

Second, there is the assumption that doctors are shying away from being judgemental about their patients. Well, if they are, good for them. Doctors would do well to heed the old advice of the microbiologist René Dubos, who suggested that the role of the wise physician is ‘to make it possible for his patients to go on doing the pleasant things that are bad for them – smoking too much, eating and drinking too much – without killing themselves any sooner than is necessary’. Doctors should treat the sick, not worry the well.

Third, such payments will only skew doctors’ focus away from making normal clinical judgement and towards meeting targets. I’ve no doubt that a doctor talking to a patient who is extremely overweight or who has just been diagnosed with type-2 diabetes will want to raise the question of losing weight as part of a programme for managing their chronic health problems. Leaping on someone who has come up suffering with earache or tonsillitis and wasting time weighing them and prescribing them a short course at Weight Watchers is directly detrimental to their care (and will doubtless have little impact on the patient’s waistline in the long run).

Perhaps most importantly, such payments would put a barrier between doctor and patient. If a patient who is actually experiencing worrying symptoms is put off a GP visit because he or she is expecting a lecture on their lifestyle, then their health will likely suffer. It also creates a bad-faith relationship between doctor and patient. We already feel the need to bullshit the doctor about smoking and drinking without having to add our eating habits to the list, too.

GPs are already hard-pressed enough without being expected to provide pointless lectures to their patients. All this latest proposal does is show how divorced from the real world health wonks and officials really are.

Rob Lyons is campaigns manager at Action on Consumer Choice.

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