Dr Phil Hammond, GP and broadcaster

The medical press has been peppered recently with stories of doctors striking off patients who aren't helping their smear and immunisation targets – but then taking them back on for free as private patients.

It's a neat ploy that may, or may not, catch on, but I'd far rather we didn't have the targets in the first place.

There's something unpleasantly paternalistic and coercive about giving doctors big 'all-or-nothing' financial incentives for encouraging patients to do what the Government thinks is best for them.

Surely it's a matter of personal choice?

Most of the female doctors I know do have smears, but several don't, including a gynaecologist and a public health consultant. They've weighed up the likelihood of help (avoiding nasty illness) vs harm (being labelled as 'abnormal' for much of your adult life) and decided against it.

Fair enough, it's their decision. So why fine their GP for it?

The case for immunisation is far more compelling, but again I know one GP with an autistic child who decided not to immunise her second boy with MMR.

I'm not sure what I'd do in that situation (are you?), but if we're supposed to be encouraging people to take responsibility for their health we shouldn't punish them, or their doctors, when they do.

Alas, I see plenty more conflicts ahead as the Government makes brave claims about reducing the number of deaths from certain diseases, and patients decide they don't want to take the tablets.

The argument was always that patients are too innumerate, anxious, ill or reluctant to prise decision making away from the experts.

True, some may not want to take over the wheel, but most at least want to see the road map and consider the alternative routes.

The closest we get to the nirvana of informed consent is in clinical trials (which isn't saying much), but new research into shared decision making shows that if you take the time to explain the risks and benefits, patients become as sceptical about prevention as doctors always were.

This is no bad thing. For too long we've put a brave face on screening and prevention in the consulting room, while being distinctly doubtful about it outside. If both doctors and patients approach medicine with informed scepticism, we're far more likely to have an honest meeting of the minds.

An excellent supplement from Quality in Health Care on shared decision making (http://qhc.bmjjournals.com/content/vol10/suppl_1/) found that – when presented with the evidence – patients are significantly less likely to opt for antihypertensive therapy than doctors, particularly when the baseline risk is low. The same is true for patients in atrial fibrillation offered warfarin.

If these findings were rolled out across the country, we might see patients who are better informed, more satisfied with the decision made, less anxious, wealthier, with more autonomy and self-esteem – but collectively with a higher risk of stroke and coronary heart disease.

This flies in the face of evidence-based guidelines and expert bodies, and if the Government were to pay you an incentive for reaching its heart disease or stroke targets you could miss out financially too.

But it's a lot more honest and grown up than the current state of affairs where, in the words of Angela Coulter, we "adopt the paternalistic view that patients cannot cope with bad news and must be kept ignorant of medical uncertainties".

If patients want to handle the uncertainty, let them have it as honestly as you can. There will, of course, be a downside for the unlucky few who have strokes and heart attacks. Having taken control of their health decisions, will they only have themselves to blame?

Guidelines in Practice, December 2001, Volume 4(12)
© 2000 MGP Ltd
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