There is a growing view that obesity is the most serious and pressing health problem affecting the western world. The report from a large study on page 743 emphasises some of the health consequences, confirming an association with increased drug prescribing in the drug groups that one would expect, namely those to treat hypertension, diabetes, arthritis, but also in other more surprising groups, such as skin conditions, infections and gastrointestinal complaints. In a recent issue Mike Fitzpatrick argued very strongly that GPs should not let themselves be manoeuvred into feeling that dealing with the nation's obesity was their responsibility. The qualitative study on page 750 gives an insight where this might lead. The picture it presents is of a group of doctors frustrated by the problem and, thinking of it as the patients' responsibility rather than a medical problem. Oddly, none discussed the bigger picture that includes the influences of the food industry and its interest in encouraging us all to eat more than we need, and the increasingly sedentary nature of our lives … Then there is the vexed question of encouraging patients to change long-established patterns of eating, when eating is associated with all kinds of symbolism, and occupying such a central area of family life. Finally, this is one of those topics where nobody seems to have spotted the potential conflict with promoting patients' choice. Policy statements tend to imply that we should all eat a less calorific diet for the long term benefit of weight loss and the accompanying reduction in cardiovascular risks. But I have always thought that many would opt for the pleasures of an unchanged diet (and do) rather than eating much less in order to live a bit longer. We have had moderate success encouraging patients to stop smoking. The message is simple (all tobacco is harmful) and the culture in the UK has, over a long period, become gradually more averse to smoking. Improving the national diet is likely to be much more complex and take much longer to succeed.
The idea that choice may not be the answer to all the ills of the NHS is echoed by David Kernick in the Back Pages (page 810). He contrasts the consequences of following strict managerial approaches with the idea of networks depending more on trust. How the trust of more traditional relationships between doctors and patients is formed, and its value, is explored in Moira Stewart's Mackenzie lecture on page 793. She identifies six key components of the patient-centred clinical method and reports that ‘it is remarkable that the same six are identified repeatedly from different perspectives.’ The lecture draws on a wide range of sources and is a shining example of the way that a scientific approach to general practice can support an essentially human, caring definition of general practice. Finally on page 816, Emyr Gravell uses an analogy with Welsh poetry to suggest that strict rules, apparently constraining choice, in the end liberate more than they restrict.
In July we carried a disturbing review by Chris Johnstone of the book Let them eat Prozac where he suggested that the huge campaign mounted to counter depression was a ploy fostered by drug companies keen to get doctors to prescribe their new antidepressants. Which is worrying when one observes other areas of mental health queuing up to demand attention — obsessive compulsive disorder and post-traumatic stress disorder, for instance. Then there are the large numbers of patients with anxiety. The Dutch trial on page 763 is encouraging. With only a little help from a guideline, GPs performed as well as the two ‘intervention’ arms of the trial. A contrasting paper on page 770, plotting trends over 15 years, reveals something interesting about Dutch GPs. While mental illness became more common over the study period, the doctors simultaneously became less willing to make psychological diagnoses. This is a tantalising observation. The authors consider a number of explanations, but favour the explanation that it follows the increasing workload that Dutch GPs are having to deal with, and the resulting stratagem to contain mental health problems. The editorial on page 739 exhorts us to start thinking of Irish patients as a group that is especially vulnerable to mental health problems, and the editorial on page 741 sets out a very cogent argument for primary care to take over routine cancer surveillance. Before readers groan at yet more demands being made of primary care, this looks like a really sensible idea which, because of the small numbers for each doctor, shouldn't be much extra to take on. Anyway we have NHS Direct taking work off us (page 790) … or perhaps not.
- © British Journal of General Practice, 2005.
