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The paradox of free GP care for patients

Free access to GP care is good for the health of the nation. This is taken as axiomatic; no proof needed, like exercise and a healthy diet. And if not good, then it certainly can’t be bad. At the very least, a zero sum.

But nothing is all good, all of the time. Obsession with eating only healthy food can develop into an anxiety disorder known as orthorexia and over-exercise leads to premature joint injuries, with athletes in their early 30s receiving hip or knee replacements. Free GP care for everyone, regardless of age, socioeconomic status and state of health, does not necessarily improve people’s health. More healthcare does not mean better health.

Doctors are capable of harming people just as often as they help them. Glasgow GP Dr Margaret McCartney has written a book, The Patient Paradox: Why Sexed-Up Medicine is Bad for Your Health, explaining the many ways in which this occurs, from over-testing and over-investigating to over-treating.

GPs spend years learning to diagnose and treat disease. A person presenting at a doctor’s surgery is likely to leave with a diagnosis and a treatment. This is good if there is something wrong with you, but not so good if there isn’t. Doctors prescribe treatments to people when there is nothing wrong with them. There are many reasons for this. The art of consulting is not as clear-cut as many would like to think. As Hamlet said to Horatio, “there is nothing either good or bad, but thinking makes it so”.

The thinking that shapes decision-making in doctor-patient interactions adds shades of grey to a canvas that, on the surface, appears black and white. Thinking that is influenced by a myriad of values, beliefs, and expectations of both doctor and patient. These influences show up like the cast from One Flew Over the Cuckoo’s Nest, vying for supremacy and contradicting each other, persistent and impossible to ignore every time a doctor asks a patient, ‘how can I help?’

Doctors prescribe treatments to people when there is nothing wrong with them. There are many reasons for this

Some of this cast include: Patient autonomy, demanding that what the patient wants takes priority; doctor’s duty to ‘first do no harm’, no matter what the patient wants; the legal system, demanding that no diagnosis is missed and everything is documented, in a society that is risk-averse where nothing will be taken on trust, only evidence; market forces, demanding that the service is efficient and financially viable, running to time but providing all reasonable services; research guidelines, demanding that individuals are treated according to the results of outcomes of population studies, resulting in hundreds of people being advised to take a treatment to prevent disease in a few; and consumerism, demanding that patients leave feeling happy, perceive that they get value for money, because healthcare is just another commodity in a free market, competing with direct access to online pharmacy diagnosis and treatment, corporate health checks and private emergency clinics. Patients are consumers and professional opinions are difficult to price and not always valued as much as a prescription or a referral.

As Peter Toon writes in A Flourishing Practice?, even seemingly straightforward consultations contain these “incommensurable fragments of moral discourse that are impossible to compare in value and size and difficult to reconcile”. The road to GP decision-making more often resembles Alice’s adventures in Wonderland than Dorothy’s rather more linear journey to Oz.

Since the introduction of the under-sixes contract, the number of parents presenting their children for ‘just-in-case’ consultations has risen. But doctors do not have crystal balls or magic potions and will on many occasions diagnose illness where there is none and prescribe medicine when it is not needed. 

Good health does not begin with visits to the doctor.  A good healthcare system should be like a sanitation system — unseen, unobtrusive, working efficiently for those who need it. Improving people’s health involves a mixture of public health policies, vaccination programmes, socioeconomic policies to reduce poverty, and provision of facilities that encourage active and engaged lifestyles. Such measures would negate the need for free access to GPs, except for those who are ill.

GPs are not the only ones who are expected to act ethically. Politicians and healthcare managers have a duty to do so too. Healthcare should be reserved for the sick.

People who are lucky enough to enjoy good health will benefit just as much, or perhaps even more, from ‘an apple a day’.

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