#GPFUQ
166 How to question people in power? Tony
Benn had five questions
What power have you got? Where did you get
it from? In whose interests do you exercise it? To whom are you accountable? How
can we get rid of you?
If you cannot get rid of the people who govern you, you do
not live in a democratic system.
#GPFUQ
167 What is informed consent? Its not informed if
the numbers that describe risk are a mystery to most people? Doctors usually
don’t know the numbers needed to treat (NNT) and numbers needed to harm (NNH)
and don’t explain the true benefits and harms of tests and treatments. Patients
usually consent with only a poor understanding of their risks. Other numbers to
explain overall benefits and risks like numbers needed to benefit (NNB) and
numbers needed to damage (NND) are used even less.
Patients
usually overestimate the benefit of treatments. For example, many people using
statins or antihypertensive’s believe they are substantially reducing their
risk of heart attack or stroke. Assuming that the treatment is safe and used
for 5 years, only a few patients would take a drug if they thought that they
had a 5% chance or less of benefiting (NNT 20). Half of the patients would take
a drug if the chance of them benefiting was 20% (NNT 5). If the benefit was 5%
or less then the number of patients willing to take a preventive drug was
doubled if their doctor recommended the treatment. Most interventions are not
that good.
Different
doctors and patients cope with the same risk differently and the subsequent
management of the same conditions varies widely.
#GPFUQ
168 How can risk and consent become better informed? GPs need to know and
explain the frequency of benefits and harms of the tests and treatments that
they recommend to patients. To be able to do this risk scores like NNT, NNH,
NNB, NND for tests and treatments need to be easily accessible to inform everyday
decision making and GPs need to benchmark their own understanding and tolerance
of risk and make this clear when they make recommendations to patients.
If patients
can make sense of their risk they will make more informed and personal choices
about their care, and may not consent to overtreatments.
#GPFUQ
169 How do you reduce emergency
hospital admissions? This should focus on all the people (patients, carers, and
clinicians) at higher risk. Better care is needed outside of hospital for
patients with chronic conditions. It is the weakest link in a chain of people
at risk that’s important. Links are weak and the risk of emergency admission
high when patients, carers, and clinicians struggle to cope with a mix of
complex medical and social conditions, the plethora of services available,
perverse incentives that confuse best practice, and the lack of effective
feedback loops to inform choices about care.
For
example, the GP is one of many factors in the mix. A series of studies of GP
out of hours services in Bristol showed a fourfold variation in emergency
referrals between the top and bottom quarter of referrers and a 10-fold
difference between the top 10 and the bottom 10 referrers. A low “tolerance of
risk” by the GP seemed to be the weak link that predicts emergency referrals.
Weak links can be strengthened by making differences in behaviour visible
through better feedback to patients, carers, and clinicians. Such an approach
might reduce variation in performance and improve quality.
