“But there isn’t any,” said Alice when the Mad-hatter offered her a glass of wine.
Morale amongst family doctors is lower than ever. Not a day goes by without us being subjected to a tirade of criticism from the media who take perverse delight in portraying us as incompetent. Last week, it was the BBC’s flagship current affairs “Today” programme having a go. Whilst interviewing
“Dr” Jennifer Wild, a psychologist from London, John Humphreys accused family doctors of “pushing” unnecessary anti-depressant medication on unsuspecting patients, and doing so because of undue influence from drug companies. “Dr” Wild said that most of these prescriptions were inappropriate as cognitive behavioural therapy (CBT) was a superior treatment. “Dr” Wild, who was styled as a “consultant psychologist”, was allowed to make her points unchallenged. Many will have assumed that she is medically qualified. She is not. She is an academic with a PhD. She is not a psychiatrist. She is not a doctor in the ordinary, everyday sense of the word. She has never herself prescribed anti-depressant medication because she is neither qualified nor trained to prescribe. She is, in fact, a cognitive behavioural therapist and she is using the ever pliant BBC to flog her stock-in-trade. This was not a news item at all. It was
an advertorial for Jennifer Wild.
CBT is perceived as the universal panacea for mental illness. Few know what CBT means but that does not stop them feeling that it is a “good thing”, unlike anti-depressants, which are a “bad thing.” Jennifer Wild is a psychologist who provides CBT. That does not give her a monopoly of wisdom nor should it entitle her to a platform from which, unchallenged, she can criticise family doctors. There is another side to the argument, which a reputable journalist would have put.
This interview caused so much outrage that, even before the programme had finished, the BBC felt obliged, at short notice, to interview an experienced family doctor. (See
here at 8.57 - it will only be available for a few days and note that characteristically, and disreputably, the BBC have removed the original interview from the listen again feature.) The family doctor made the point that, whatever the mad hatters at NICE may recommend, CBT is not widely available on the NHS. John Humphreys responded with the infantile remark that he had some friends who had had it.
This tawdry, one-sided interview has done yet more damage to the “Today” programme. John Humphreys used to be an outstanding political interviewer. Always self-opinionated, he now presents his opinions as fact, and his aggression has gone beyond burlesque. He joins Jeremy Paxman to become one of the two pantomime dames of political commentary. Humphreys is entertaining, but he is no longer a trusted arbiter of political balance. Under his stewardship, the “Today” programme is becoming a pantomime of political punditry. It is time for this Welsh Widow Twankey to move on to a more appropriate forum. There is, I understand, a vacancy in Strictly Ballroom.
It’s not just John Humphreys. This week, still fuming about Jennifer Wild, I woke to the dulcet tones of the more moderate James Naughtie telling me that I needed educating so that I might be better able to diagnose cancer. It’s still nonsense, but at least we were spared Widow Twankey’s take on it. I’ve covered it
briefly in the Guardian today but space did not allow for much detail. The UKs relatively poor performance in cancer care is a resource issue. We do not have enough oncologists, and the oncologists we do have are unable to access the front line chemotherapy that their colleagues in Europe and the USA use routinely. We do not have enough radiotherapists. The radiotherapists we do have do not have enough kit. The treatment of lung cancer in this country is
particularly dire for
those (most) patients who cannot afford to go privately. The government tries to paper over the cracks by appointing
lung-cancer nurse specialists but, well-meaning those these nurses may be, they are no substitute for front line chemotherapy and linear accelerators.
Mike Richards is the government’s cancer “tsar”. (God, I hate this fashionable but absurd use of this archaic word). He represents the government’s view on cancer. He is paid by the government. He is telling us that much of the problem is due, not to lack of resources, but to delayed diagnosis in primary care. (Think about that carefully. There is a huge logical flaw in the argument. Can you spot it? - answer at the end). Mike Richards points to the relatively fast diagnosis of cancer in Kensington and Chelsea area compared with slower diagnosis rates out in the boonies of Herefordshire. Is this really a failure of primary care or is it more to do with resources, in particular, the concentration of resources? Those pushy middle class patients in Kensington and Chelsea are in walking distance of the Royal Marsden post-graduate cancer centre, and a short bus ride from half a dozen internationally known centres of excellence. One of the benefits of living in London. Compare the resources available to a Londoner to those available to someone living in Anglesey. Are we to conclude that all the family doctors in North Wales are bad at their jobs?
Health care rationing is inevitable. The only decision we have to make is whether we are going to take control of the rationing ourselves, or let the health care “market” do it for us. And the market will be run by Daily Mail readers, demanding avastatin or herceptin for their relatives whether or not these drugs are appropriate. The National Institute of Clinical Excellence (NICE) is an attempt to take control, and allocate resources in a rational manner. NICE limits the availability of front-line cancer drugs. Many of these drugs are in routine use in other countries; countries that spend more of their GDP on health care than we do. You can only spend the taxpayers’ money once and, just at the moment, our democratically elected government is giving priority to guaranteeing the banks and the bankers bonuses, to fighting the war in Afghanistan, to paying the huge cost of EC membership and so on. It may well be that these decisions are appropriate. That is a matter for the electorate.
However, although some of the decisions made by NICE are suspect, the general principles upon which NICE operate are correct. What ever you think of NICE, what they are trying do is better than a postcode lottery. It sounds hard, but spending millions to extend the life of someone who is terminally ill by a few weeks is not good economics. Conversely, today’s new, semi-experimental drugs may be tomorrow’s routine treatment. In my short medical life, I have witnessed a significant number of cancers go from being an automatic death sentence to being controllable or even curable. This could not have happened if the last two or three generations of oncologists had not been able to push the treatment boundaries ever wider.
Someone has to make resource decisions. The decisions that have been made in the UK over the last ten years or so have meant that our cancer survival rates have fallen behind those in Europe. Let the government be open and honest about this being a resource issue, rather than trying to fudge and obfuscate. There is always scope for the better use of resources, and we must optimise diagnostic services in primary care. But the problems will never be solved whilst resources are inadequate. The government and its advisors need to admit that openly. But, as Professor David Nutt has shown us, with this government, it takes a brave man to stand up and speak honestly.
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(The flaw in the poor primary care hypothesis. Let us assume that GPs are indeed appallingly bad at diagnosing cancer. Let us then assume that they are "retrained" or "educated" so that they can diagnose it swiftly and accurately. The hospital cancer services would immediately be swamped with referrals and even less able to cope with the workload than they are at present)
