April Focus

David Jewell

‘Are we all the dupes of the pharmaceutical industry?’. The review of Malcolm Kendrick's The Great Cholesterol Con on page 336 argues that we are all being duped, but doesn't go so far as to direct the blame at the pharmaceutical industry. However, the reviewer feels that the book should ‘make us all uneasy’. Take, for example, the comments made about the lack of benefit in primary prevention; benefit is only proved for men with established ischaemic heart disease, and even for them it only amounts to a few days for each year of taking the drugs. On page 332 Michael Weingarten writes about the sanctity of life and challenges the whole idea that a few extra days of life are what matter. You may disagree with the argument, or the religious tradition from which it stems (and I should declare an interest here). However the general line — that the value of a life cannot be measured only by its length — will have strong echoes for many readers if they think about it not in relation to their patients but to their families, or indeed themselves.

Another echo comes from the discussion of multiple morbidity. In the last few years this has become a rallying cry for general practice and it is explored on page 268. The difficulty is simply stated: that all of current medicine in the UK is being driven by guidelines drawn up for single diseases, themselves almost entirely based on research carried out on otherwise fit individuals affected by a single problem. Most of our patients with these problems are older, when multiple morbidities are the norm, and it is unclear to what extent the guidelines still apply. Apart from anything else, as the editorial points out, we need to measure outcomes in terms of health and function and not extension of life. Research on multiple morbidity has been limited, and there is a pressing need to develop robust outcome measures.

The current danger for general practice is if we are tempted to use ‘multiple morbidity’ as a mantra to guard our own turf and to ward off outside influences without making the effort, both intellectual and practical, to define the phenomenon and its effects, and work out how to respond to it.

Three papers this month make tentative steps at opening up what has up until now been one of the black boxes of medical care. The systematic review on page 319 reports that progressive disability is more likely in the presence of cognitive impairment. Not surprising, but an important pointer how multiple morbidity may be operating. Then two papers illustrate the need to develop functional measures of outcome, and try to unpick the complicated interaction of social and physical aspects of health. Both living alone (page 271) and a sense of isolation (page 277) are associated with worse function. At the same time they are a reminder to be very careful: living alone and isolation are not the same, so that half of those scoring high on the isolation scale were living with someone else (page 277).

Here is the next big challenge to the world of primary care. For a long time we argued that we stood for personal care. Here in the UK we seem to be providing less of it than we used to, and at last the evidence is coming through to support what has been a plausible but unsupported claim. Perhaps it matters less whether we set out to provide it or not. The patients surveyed in the study on page 283 seem to be able to get personal care for themselves if they want it. Right now, the claims for the importance of multiple morbidities, and who doesn't fit into the single disease categories are just the same: convincing but without convincingly irrefutable evidence to support them. The incessant demands for GPs to take on more responsibilities will continue, but we should resist them.

No need, for instance, to take on more screening. PSA testing confuses everyone — doctors and patients alike (p303); screening for peripheral arterial disease can be done, but the yield in clinical practice is much less than the research studies suggested (page 311); and the latest wheeze that our political masters in the UK have been visiting on us, asking GPs to take responsibility for the effects of their rush to liberalise gambling, should be resisted at all costs (page 327). But the patients with multiple morbidities are with us here and now, in large numbers, and they may be the ones who stand to gain most from the expertise of skilled generalists providing good personal care.