So, what is really going on here? A review group on health matters is reported to be proposing that people should be asked about their diet, alcohol intake and other habits whenever they see a health professional – even if the reason for the conversation has nothing to do with how fat or boozy they might be. The Guardian reports as follows:
Patients should be asked about their diet, smoking and drinking habits every time they see a health professional according to radical proposals from the government’s NHS advisers to tackle soaring rates of obesity, cancer and alcohol misuse. The NHS Future Forum wants health staff to routinely talk to patients about their lifestyles, even when they are suffering an unrelated illness, and offer them advice and help to become healthier.
So far, so reasonable. After all, part of the social contract involved in a welfare state is that we own up to a mutual responsibility to the service. If my lifestyle choices are costing others, then I can have no objection to being asked questions. And again, after all, the questions are aimed at my better health and best interests, aren’t they?
The statistics almost beggar belief:
- The number of people in the UK with diabetes has risen by almost 130,000 to 2.9 million in the last year. That is up by almost 50% in just four years (2006-7 to 2009-10). Some 90% of these 2.9 million have Type 2 diabetes, which almost always develops in people who are very overweight.
- The Lancet medical journal has conservatively estimated that, on present trends, by 2030 obesity in the UK will have produced 5.45m cases of diabetes, 330,000 more people with coronary heart disease and stroke and 87,000 extra cases of cancer, which together will mean a loss of 2.2m quality-adjusted life years in the population, and costing the NHS another £2.2bn a year on top of the existing huge price of tackling obesity-related illness.
Yet, the Guardian report continues:
But some medical leaders last night voiced fears that such interventions might stop some patients from seeking medical help in case they were asked questions they found uncomfortable, and the Patients Association said it was “overkill”.
Of course the questions are ‘uncomfortable’. Isn’t that the whole point? They are supposed to be uncomfortable if they call into question the effects and consequences of our choices or habits. But
that is no argument for not asking the questions. The guy leading for the government on this gave an example:
… A podiatrist who’s looking after the feet of a diabetic patient has an absolute responsibility to talk to the patient about their smoking, because smoking makes diabetes worse and means the patient is more likely to have a foot amputated.
Now, anyone who has ever been phoned by a journalist knows the sorts of games that might be being played here. However sensible the substance of the story, someone has to be found who will object. (A bishop says the sky is blue and the National Secular Society is called to object…) And it is often the case that the person being called is told a rather biased story to which the desired response can readily be given and the ‘story’ is then complete and ready for publication. I have no idea, therefore, how the ‘objections’ to the proposals above were elicited, but I do want to be wary about taking them at face value (and would be interested to know if those quoted feel that they have been quoted justly).
Why this interest? Well, simply that what really interested me about the story was the choice of words used by those who aren’t so keen on the proposals. Try this for starters:
But Dr Clare Gerada, chair of the Royal College of GPs, said the policy was “muddled” and some patients might be put off by what they saw as intrusive questioning. “Young men pluck up the courage to go and see their GP, maybe about a sexually-transmitted infection, and would not want to be lectured. So we have to be careful that we don’t impose our agenda on to the patients and don’t inadvertently frighten patients who are coming in to see the doctor and who fear that they might be preached at,” said Gerada.
Er… ‘preached at’?’ ‘Lectured’?
Why these words to describe questions that need to be asked precisely because they are uncomfortable? The patient doesn’t have to answer them. As any doctor will tell you, you can double the figure any patient gives you when asked about weekly alcohol intake. But, since when has the asking of relevant health questions been synonymous with ‘lecturing’ and ‘preaching at’?
The economic price, as measured in lost productivity, welfare payments and the cost to the NHS, are already mind-boggling. Diabetes costs £10bn – almost a tenth of the entire health budget. That includes £725m spent on drugs for diabetics, and the cost of hospital beds – one in seven is occupied by someone with the condition. Yet every expert believes that, without a major change in human behaviour (which no one expects), these costs will only rise. These lifestyle diseases have been increasing at the same time as the risks of unhealthy behaviours have received unprecedented attention. Everyone knows that cigarettes are ruinous, but one in five still smoke.
… Professor Steve Field who chairs the forum admits: “Not enough people take enough responsibility for their own health, despite the amount of information that’s available.”
But, if this challenge to individual, personal responsibility needs to be heard loudly and clearly, so does the warning to society generally need to be heeded:
Katherine Murphy, chief executive of the Patients Association, said it agreed that patients needed more advice on living more healthily and help to do so. “But the underlying factors causing unhealthy lifestyles, for example poverty, also need to be addressed.”
So, happy new year to you! And my advice to myself and everyone else? Drink less alcohol, eat less, get more exercise, … and welcome ‘intrusive questioning’ about all three. It might make the difference between a healthy and a miserable 2012.
December 31, 2011 at 6:01 pm
I gather most GPs have had less than one day’s worth of tuition in dietetics and the only one who queeried me about alcohol intake didn’t know how many units in a pint of Guinness compared to weaker beer or stronger lager.
HMG might start by ensuring that GPs are better educated and tackling advertising of sweet and junk foods.
Many young people are still unaware of tge dangers of overweight and diabetes. It will cost money to educate them and I doubt that many GPs will take such initiatives if no move is made on the junk food companies.
December 31, 2011 at 7:01 pm
It’s all about getting some perspective and balance into the matter. If GPs and nurses are going to interrogate people, it could be counterproductive – people will tell ‘porkies’. No, ask me uncomfortable questions alright, but we all can do with some mercy and kindness. Those qualities make us feel better, and maybe actually make us better too. Good wishes for 2012!
December 31, 2011 at 8:57 pm
Well, while I might say that asking such questions won’t hurt and might help, what would be of more help (and I speak as someone who has been overweight most of his life, and has had type II diabetes for possibly as much as a quarter century) is concrete help with weight loss for us. Smoking cessation is a big deal with the NHS nowadays (I don’t smoke so I have not paid much attention to it), and alcohol needs to be made less available, more expensive, and child-proof.
I do not believe that a doctor asking a teenager coming in because of symptoms of a STD about his drinking and smoking habits will do anything to nudge that teen away from drinking and smoking.
The reason this is being advanced as a policy is that asking someone about their eating habits is much cheaper than performing a gastric bypass on an overweight man or woman. Asking someone about their alcohol consumption is cheaper than prescribing Antabuse for every alcoholic. Asking someone about their smoking habits is cheaper than further restricting smoking (which would cut tax receipts from tobacco).
By all means, GPs should be aware of their patients’ smoking, drinking, and eating habits. But thinking that questioning their patients about them every time they see them will do anything to change those habits could only be thought efficacious by a very idealistic doctor.
December 31, 2011 at 9:13 pm
Ian, how quickly ‘questioning’ became ‘interrogation’!
December 31, 2011 at 9:16 pm
Chris Hansen, I am not quite so cynical of the motive. A change of lifestyle is the only way to change things, but how to actually achieve it is beyond most people’s imagination. I agree that such questioning won’t of itself change much (or get young people to change), but there is no reason why it shouldn’t be one important element in a more differentiated approach.
January 1, 2012 at 8:02 am
Questioning and interrogation… There can be a fine line in patients’ perceptions!
January 1, 2012 at 3:05 pm
Excuse me if I sound sceptical but has anybody considered just *when* all these questions are going to be asked? I recently visited my GP [one I rate, having experienced a few] because I thought I needed antibiotics. When I entered the room she was busy feeding information into her computerised database [about me, or the previous patient?]. She listened while I glossed my problem[s] with one eye on the computer screen, one hand on the keyboard, then searched the screen while I removed several layers of clothing [it was a very cold day and I was unwell] so that she could listen to my chest, peer down my throat and into my ears and make a rapid assessment. Questioning did then follow concerning such matters as whether I was allergic to any types of penicillin, the precise nature of my symptoms, how long I had been suffering etc etc Then she printed off a prescription form and signed it, gave a quick explanation of the type of antibiotic she had prescribed, and I left [having struggled back into my clothes in a hurried and undignified fashion].
I just got this off “netdoctor” :-
“Most GP appointments last an average of seven minutes – so by the time you’ve walked in, said hello, explained why you’re there and been examined, there’s not a lot of time left for small talk.
In fact, research suggests most people only remember a maximum of three facts from a consultation and many leave having forgotten to ask a key question.
Use the following tips to make the most out of your time with your doctor.”
One of the tips is … guess what?
“Try to only talk about one problem at a consultation.” !!
January 1, 2012 at 4:36 pm
I wish that type 2 diabetes ‘almost always develops in people who are very overweight’. I am 14stone 6 lbs, 5’11″ in height and play badminton twice a week. I am not very overweight. I have type 2.
The association of illness with morally dubious lifestyles is one which can be taken too far.
January 1, 2012 at 5:08 pm
Yes, dearsoeur, there is limited time and the questions put to you were clearly for the purposes of diagnosis and treatment. Very important, very correct. However, the Guardian report referred to questions being put every time a “health professional” is seen, so this could be a nurse – also busy – or someone else – also busy, no doubt. (Just who has the right to ask us questions about our health is an issue, which doubtless could be debated into 2013. European Union legislators might have a view, too.) General check ups are useful, but I wonder what a receptionist (health professional?) might say if one tried to book an appointment for that purpose: “I feel fine, but I’d just like a check up, please.” Maybe it would be okay. It would be nice to think so. Perhaps if GPs sent out annual questionnaires to their patients actually enquiring how they are, it might be quite appreciated! It could even be done by email. But just once a year please, doctor. Thank you.
January 1, 2012 at 7:05 pm
I think medical professionals have a duty to challenge patients about unhealthy lifestyles and to advise them, although frankly GPs are not the best people to advise on diet or that more important element exercise.
There is, however another facet to this relationship. As an older person i am now subjected to increasing medicalisation. I am pressed to submit to this screening and that and told that I need to take preventative drugs that hjave side effects that are hushed up. It is fine for some of this to be fofered, but it gets to the poimnt where I feel that the GP is not listening to me and my desires about my lifestyle. My personal choice would be to lead an active and exjoyable life for as long as possible and then to die quickly. I know I cannt arrange that but I can influence it, by exercising hard which I do and controlling diet. When this crosses over into taking drugs which will reduce my active life but prolong my overall life, or when i am pressed to take tests which may reveal latent disease which may result in ealrlier medicalisation then this infringes upon my personal choice, faith and ethics.
Overlay that with the fact that most of the statistics about preventative drugs andothjer treatements are prepared by people with a vested interest, the pharmaceutical and bio-medical companies and we see a system beginning to run out of control. It is not for the Government, or medical industry to make decisions about my health, how long I should live and to try to keep me alive in degraded circumstancwes for as long as possible whilst they raid my bank account and it is most certainly not for my GP to assist them and get rewareded for doing so.
We need to think more deeply about the value of life, active and demented, and about what values we as a society espouse. Surely, as Christians we have much to say here, but I don’t hear it being said.
January 1, 2012 at 7:33 pm
Thanks for helpful comments – especially giving a corrective on assumptions behind diabetic condition (although the stats still look worryingly clear about the lifestyle link) and the feasibility (apart from desirability) of questioning.
Any comments on (a) the language matter I highlighted or (b) the economic imperative vs personal freedom question?
January 1, 2012 at 8:29 pm
Well, Nick, here’s how I for one react to the three points in the text:
[1] Quote: “But Dr Clare Gerada, chair of the Royal College of GPs, said the policy was ‘muddled’ and some patients might be put off by what they saw as intrusive questioning.” Reaction: It’s about how patients perceive what’s going on. I think there can be a vast distance between doctor and patient (education, social standing, ability to articulate oneself) and in good pastoral style doctors need to be able to get alongside their patients. That allows the patient to be more confident in the doctor and maybe even like the person. All that helps, I think. I like my doctor. When I once asked him if I could have a cider with lunch while on certain medication he said he hoped I would ask him along!
[2] Quote: “Young men pluck up the courage to go and see their GP, maybe about a sexually-transmitted infection, and would not want to be lectured.” Reaction: It seems to be accepted that men are bad about going to their doctors and I certainly believe that, when they do go, they (and women too) should feel good about the relationship. There are ways of getting messages across and, given the time constraints mentioned earlier in this discussion, every minute must be used well. It can take a long time to row back from an unfortunate exchange of words, and sufficient time really to work at the doctor-patient relationship is not there. I’ve heard of really poor bedside manners on the part of ‘health professionals’ and I just think that is inexcusable without an apology. When a doctor is rude, he or she should be told so; after all, if the patient is rude, he or she will certainly be told!
[3] Quote: “‘So we have to be careful that we don’t impose our agenda on to the patients and don’t inadvertently frighten patients who are coming in to see the doctor and who fear that they might be preached at,’ said Gerada.” Reaction: Preaching seen as lecturing? Actually, perhaps not really here. The term Dr Gerada uses is “preached at”. To preach ‘to’ a congregation is not the same as preaching ‘at’ a congregation. Preaching ‘to’ is fine, preaching ‘at’ is a bad approach. It alienates people. Yes, the verb ‘preach’ can be used colloquially in the pejorative sense of ‘lecture’, but that isn’t how Dr Gerada uses the term. Yet the terminology does tell those who are preachers that they have to use a style that avoids any talking ‘at’ people.
January 2, 2012 at 9:52 am
Hi Nick,
I hope the government gives these proposals short shrift. Attempts to micro-manage consultations between medics and patients change the nature of these vital, confidential relationships. This is not about the link between lifestyle and health but about imposing checklist bureaucracy in an inappropriate way upon professionals in whom we should invest greater trust and confidence that they might have a clue themselves how such subjects are broached properly with their own patients.
January 3, 2012 at 12:36 pm
Andrew, happy new year to you. I agree with you about the sensitivity and confidentiality of the patient-doctor relationship (although the proposals are not just about doctors), but still question whether that rules out a responsibility – as part of the ‘contract’ of rights and responsibilities – to look at people in the round and ask questions where appropriate. Maybe I’m a freak, but some of the best interventions I have had from medics have arisen from what might have appeared at first sight to be unrelated questions. Also, I wonder if what you say would hold in other areas of life such as education, etc.
January 3, 2012 at 2:35 pm
Happy New Year. Confidentiality applies across all the relationships between patients/doctors/nurses. And your own experience bears out the fact that these links are already made appropriately. And yes, I think the tendency for the state to become inappropriately involved in all sorts of relationships especially in education needs to be rolled back. This isn’t a party political point, it’s about subsidiarity. Let’s only manage what we absolutely have to.
January 4, 2012 at 1:28 pm
“And yes, I think the tendency for the state to become inappropriately involved in all sorts of relationships especially in education needs to be rolled back.”
That’s a fine sentiment, and I don’t disagree; but the problem is that as more and more people depend on public expenditure to live on, you have give them “something to do”. Bureaucracies keep expanding in modern democracies beyond the ability or willingness to tax, hence the sovereign debt crisis. Over 70% of expenditure in Scotland, Wales, N.I. and the North-East is public money. These are also the (largely) post-industrial areas where poor diet, smoking and over-consumption of alcohol figure more frequently. Now imagine if people had to pay a health insurance premium based on their lifestyle!