A Salvation Army without the brass band
Doctors should refuse to become the high priests of the new anti-boozing temperance movement.
spiked is currently publishing a series of articles based on talks given at the Battle of Ideas festival, which took place on 1 and 2 November at the Royal College of Art in London. Here, Dr Michael Fitzpatrick argues that general practitioners (GPs) should only treat people’s drink-related health problems and not preach to them about the dangers of boozing.
I would not dispute that alcohol causes damage to health. I am sure there is hardly anybody that has not got a personal experience of the damage that alcohol can do, either to themselves, their family or to their close friends. But I want to argue that just because something has consequences for health, that does not make it ipso facto a medical problem. This seems to be the central problem with the current focus upon alcohol as a public policy issue and the role of doctors within it.
Since doctors experience the adverse effects of alcohol in terms of people’s health, it is a very alluring prospect for them to think ‘if only I could do something to prevent this, it would make my life much easier’. This signals a retreat from the arena of treating problems as they present themselves in the doctor’s surgery into some other arena.
The difficulty does not lie so much in whether or not the measures proposed will be helpful in preventing the harm caused by alcohol. What I am worried about is part of a much larger trend, and that is the retreat of doctors from their own sphere of expertise – the diagnosis and treatment of disease – into other spheres. By this I mean that they take on the role of other sorts of professionals, of politicians, making social policy, making legislation; of priests, preaching to people as to how they should change their behaviour; or indeed, of the shock jock, appearing on television chat shows and radio shows, telling everyone ‘the end is nigh’, ‘we’re in the grip of a terrible epidemic’, ‘something must be done’, ‘we’re sleepwalking into disaster’, and promoting alarming figures of the enormous costs of these problems. Not that there aren’t problems, of course, but there is always a tendency to exaggerate greatly, to promote alarm, and to provoke anxiety around these issues because that might be useful in promoting some sort of intervention.
It is interesting to look at these sorts of things historically, because we have been here before. It is striking that there are three periods historically when alcohol becomes the major political and cultural debate. And we seem to be entering into a period like this now.
It happened in the middle of the eighteenth century with the gin craze in London. We had it in the early nineteenth century with the first phase of the temperance movement. And we had it at the beginning of the twentieth century with the revival of the temperance movement, not just in this country but internationally, which culminated in the United States, most notoriously, enforcing prohibition – which is generally agreed to have been a catastrophically disastrous intervention of the state in trying to regulate alcohol which caused a massive crime problem from which the USA is yet to recover.
We seem to be entering a similar period again. I was recently reading an introduction to a historical discussion of the temperance movement published in the 1960s, which starts off by saying that ‘nobody is interested in alcohol anymore because people think the alcohol question has been solved’. And then in the second edition of the book, published in the 1990s, it effectively said, ‘great, this book is of much more interest because now there’s a return of alcohol to public discussion’. It is strange, then, that during the entire postwar period there were virtually no big public discussions of alcohol. Of course, people were still drinking themselves to death during that period, and alcohol was undoubtedly causing an enormous amount of health and social problems. But it just wasn’t an issue of major political and social concern.
So what we see are these periodic upsurges of concern about alcohol, which seem to combine two elements. I do not think it is just a moral panic; usually there is some change in the way that alcohol is dealt with in society, as I think we have seen over the past 10 years. There is always a wider, cultural and political context that leads to alcohol becoming a major focus of concern. It always involves a combination of medical and, historically, religious factors, usually involving evangelical preachers. Hence there has always been a moral and medical element to it.
What’s distinctive about the current phase of the alcohol issue is the ascendancy of the medical profession – there are three doctors and a psychologist speaking on this platform today [at the Battle of Ideas]. I do not think that would have been the case in the temperance discussion in the early years of the twentieth century. In a sense, we now have the Salvation Army without the brass band, which may or may not be considered progress.
The thing that strikes me most about this contemporary discussion was well drawn out in a feature in the Guardian a couple of months ago. There was a whole section on the problems of alcohol in society, and in bold print it stated as a conclusion ‘your GP is the first place to turn to if you’re concerned about your drinking’. ‘Why?’ I thought to myself. Why would anyone think that the family doctor is the person to go to if you think you have a problem with drinking, other than the fact that the traditional GP’s definition of an alcoholic is someone who drinks more than he himself drinks. (I also read somewhere that the occupation that has the highest incidence of cirrhosis of the liver, after bar men, is GPs. So perhaps this confers some particular expertise in the area of liver problems.)
The National Audit Office just published another report called Reducing Alcohol Harm. The central theme of this particular report is the role of GPs in dealing with alcohol harm, and a critique of primary healthcare trusts, saying that they are not doing enough to incentivise GPs to monitor their patients’ drinking habits, to record them, to screen them, and to deal with them. The central theme of all these reports (and there’s a huge amount of policymaking in this whole area) is that early intervention with problem drinkers can reduce the enormous burden of cost in terms of ill-health and treatment. And, of course, that is what everyone would like to see. If only we could intervene earlier to prevent it, then we would not have to deal with it later. Early intervention will reduce the burden of later cost, apparently – this point is repeated three times in an abridged summary of the whole report.
But what is the evidence that this is true? This is actually a new form of one of the oldest fallacies in the health service, promoted by the Beveridge report, named after William Beveridge, the founder of the UK National Health Service (NHS). And Beveridge’s famous fallacy was that early expenditure in the NHS on prevention and improving people’s quality of health would lead to reduced health expenditure in the long term. Exactly the opposite came to pass, for the simple reason that spending on prevention will only deliver a long-term result if the prevention is effective in relation to the public targeted. And this is the central problem with intervention and alcohol.
Here we come to the notion of ‘brief intervention’. The idea of brief intervention in general practice is the central theme of every policy in the area of drinking. All the documents will claim robust evidence that brief interventions by GPs – that is, 15- to 20-minute consultations – are very effective in changing long-term drinking habits.
All of this would be brilliant if it were true. But, if you stand back from it, it couldn’t possibly be true, this idea that all that is needed is for a GP to talk to a patient for 10 minutes and everything will be solved. We’re in fantasyland here. This is wishful thinking elevated to the level of government policy.
If you look at the robust evidence about the efficacy of ‘brief interventions’, you will see a whole number of ways in which this so-called robust evidence is constructed. First of all you exclude anyone from your study who is dependent on alcohol; that is, alcoholics. You then look at what is considered to be effective. Is it stopping drinking entirely? No – any reduction in alcohol consumption is considered to be effective. In fact, any reduction in episodes of binge drinking, however that is defined, is considered effective. And that is all that is required to show efficacy.
The other thing that is very important is to shorten the time over which you decide whether the intervention has been effective. Most use a few weeks, or at most a few months. None for longer than a year. So you can show that if GPs talk to someone for 10 to 30 minutes it might reduce the amount they drink for a very short period of time, for the people who don’t drink very much in the first place. This is considered to be robust evidence of the efficacy of brief intervention, which now informs a whole body of government policy and incentives to deliver these interventions to patients.
Any questioning of the studies provokes outrage. The very act of critically appraising research of such low quality subverts the government’s public health message and it is apparently scandalous to the public to suggest that brief interventions by GPs are not terribly effective.
So, all right, it doesn’t do any good – but surely there is no harm if GPs explain to patients why alcohol might cause them harm? I think it is harmful. First of all it infantilises patients. The idea that you screen everyone who comes in, and start lecturing them about drinking habits, that this is a notion of good medical practice – that seems to me demeaning for the relationship between a doctor and a patient.
It is interesting how contrary all of this is to the prevailing ethos of general practice, which is very critical of traditional paternalism, of a paternalistic relationship between the GP and their patient. Yet the brief intervention approach to drinking entirely relies upon paternalistic relations between a GP and his patients. On what basis would a patient change their attitude to drinking having spoken to a GP other than their deference to an authority figure? This is not something that should be promoted in general practice in any way.
The promotion of brief interventions and anti-drinking strategies in general is also degrading to doctors. It affects general practice by changing the role of the doctor from dealing with problems that the patients present them with, to in some way exhorting them to change their behaviour in order to improve their health. That is not a useful form of medical practice in terms of either the patient or the doctor, or indeed the whole practice of medicine, which comes to be reduced to a form of lecturing and hectoring.
GPs are increasingly expected to intervene in patients’ lives. As a GP I am now obliged to counsel patients, not only in relation to alcohol, but also in relation to domestic violence, teenage pregnancy, elder abuse, drug abuse; the list is endless. One research paper that is critical of the alcohol ‘brief intervention’ idea points out that if the GP follows to the letter the types of activity he is expected to engage in today, it would take up 7.4 hours of each working day with his patients.
I conclude with the wise words of HL Mencken in response to the prohibition wave in the 1920s: ‘The role of doctors is not to make people virtuous, but to save them from the consequences of their vices. The physician does not preach repentance; he offers absolution.’
Dr Michael Fitzpatrick is a GP working in Hackney, east London. His new book, Defeating Autism: A Damaging Delusion, was published this month by Routledge. (Buy this book from Amazon(UK) or Amazon(USA).)
Previously on spiked
Lee Jones analysed the moralistic myth of the ‘demon drink’. Josie Appleton argued against all booze bans. Brendan O’Neill questioned the politics of misbehaviour. Elsewhere, he thought the debate about binge drinking was a licence to bash the masses. Neil Davenport noted how Britain is undergoing prohibition by stealth and wondered if the government knows its limits. Or read more at spiked issue Drink and drugs.
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