Jeremy Laurance: The medical flaws that should make doctors blush

Tonsillectomy and hysterectomy are operations still performed too often, on too many patients
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The Independent Online

If you happen to be reading this in a GP's surgery, outpatients clinic or hospital ward, may I offer you my best wishes and the hope that you get better soon? I am sure the doctors treating you will do their best. Unfortunately, their best is likely to fall a long way short of the ideal. And the Government's chief medical officer, Sir Liam Donaldson, is worried.

Take the overweight woman in the corner waiting for her appointment in the diabetes clinic. Evidence shows that fewer than one-quarter of diabetics, of whom there are more than a million in the UK, have their blood sugar level measured regularly. Yet poor control of blood sugar can lead to kidney failure, blindness and amputation of limbs.

The middle-aged man sitting next to her has high blood pressure, but the evidence shows that he is likely to receive less than two-thirds of the care he should receive. Fewer than half of patients with heart disease receive the drugs that can cut their risk of premature death by 20 per cent.

These are findings from the world's largest study of the quality of medical care. Elizabeth McGlynn and colleagues from the Rand Corporation, a US public-policy think tank, looked at the care delivered for 30 conditions including diabetes, asthma, high blood pressure and heart disease to 13,000 patients in 12 metropolitan areas across America, from Miami to Seattle.

What they found ought to make every doctor blush and every patient nervous. Overall, adults received about half (55 per cent) of recommended care. For the rest, they were either given treatments they didn't need or not given treatment they did need. And this in the best-funded healthcare system in the world.

Remarkably, everyone was at broadly equal risk for receiving poor care, no matter where they lived or their race, sex, gender or financial status. Rich and poor, black and white, male and female, old and young - all were equally likely to get the wrong treatment.

This theme has been taken up by Sir Liam Donaldson, the UK's top doctor, and forms the lead chapter of his annual report, On the state of the Public Health, published last month. When Sir Liam speaks - and he made it clear that he believes the findings of the Rand Corporation study apply equally to Britain - ministers listen.

Sir Liam has spent eight years in post and has established himself as the most successful Chief Medical Officer of modern times. His prodigious work rate has resulted in a string of reports which are already transforming medical care. His work on patient safety has propelled Britain into the front rank of nations examining ways of making care safer. His office, whose influence and independence were seriously curtailed under his predecessors, has regained its confidence. He took on John Reid, former health secretary, over the ban on smoking in public and won - to the initial fury of the minister.

Now Sir Liam has turned his attention to his own profession. In two reports delivered within a week last month - on medical regulation and the public health - he has challenged doctors to change the way they behave.

Ten million decisions are taken every day in the NHS and every one affects the quality of care that patients receive as well as resulting in expenditure by the taxpayer. Huge sums of money have been devoted to increasing the number of patients treated, shortening waiting times and delivering extra care. But who is asking whether what the NHS does is the right thing to do?

This is not a new problem. Clinical variation - the way doctors differ in what they do - has been observed for decades. Sir Liam cites the examples of tonsillectomy and hysterectomy as examples - operations which are still performed too often, on too many patients, unnecessarily. Yet angioplasty, the non-surgical procedure for expanding blocked coronary arteries in sufferers from heart disease, is still denied to too many patients for whom it is necessary.

Enormous research effort has been expended on trying to understand the reasons why doctors who know what they should do then go and do something different. It is not just a lack of knowledge, it is about priorities, custom and practice. But, Sir Liam said, the solution has not been found.

It has to be found, if the NHS is to survive. One answer may be to adapt what a former head of the Department of Health's NHS strategy unit called "creative destruction" - the introduction of mechanisms to encourage effective interventions and, more importantly, abandon ineffective ones. Sir Liam hints at this with proposals that the National Institute for Clinical Excellence (Nice) should offer guidance on disinvestment from established interventions "of no proven value", and that the NHS tariff for hospital care might penalise GPs who ordered "ineffective" treatments.

At the press conference to launch his report, Sir Liam described a conversation he had had with a senior surgeon at a party. He suggested the standard operating procedures used by pilots and air traffic controllers in the airline industry, which has an enviable safety record, might be needed in health care. The surgeon's response was that if that happened, "we might as well go and work in factories".

Sir Liam said: "That is not the attitude we want. We must have a more enlightened approach." Indeed, we must. The health of every patient in every GP's surgery, outpatient clinic and hospital ward depends on it.