Tag Archives: healthcare

Should we just give up trying to tackle obesity and smoking through behavioural change?

Studies of behavioural interventions (trying to make people lead more healthy lives) consistently show small effect sizes. An effective smoking intervention would improve quit rates by four per cent1 and a successful weight loss intervention would do well to produce a sustained weight loss of more than five per cent of body weight.2

The really big gains in public health have come not from behavioural change, but from public legislation. Take a few examples:

  1. Forcing tobacco companies to advertise the harms of tobacco.
  2. Raising taxes on alcohol and tobacco.
  3. Seatbelt legislation.

Governments are now considering legislation, regulation or fiscal policies to reduce excessive calorie/sugar consumption. But can we really rely entirely on these measures – should we withdraw funding for research into improved behavioural interventions? I don’t think so for two principal reasons:

  1. There are limits to what can be achieved by public legislation. A classical example was prohibition in America in the 1930s. In the end, it did far more social harm than good. There are limits to how far we can get by coercive means. Very high taxes on tobacco can actually increase consumption by fostering a lucrative black market.3 History repeats itself. Sooner or later, we’re going to have to rely on individual motivation to provide health gains that cannot be achieved by government action alone.4
  2. Many interventions, although of modest effect, can still be highly cost effective. It might be true that a behaviour change can achieve only a four per cent reduction in smoking but the interventions are often relatively inexpensive, and the health effects of a four per cent reduction are impressive when compared to many clinical treatments. In short, we should not be deflected from doing what we can to promote behaviour change on the grounds that the effect sizes are of small magnitude – they are often worth having, i.e. highly cost effective5.

Of course, all this leaves open the important question of how best to achieve behaviour change. There are a large number of psychological and social theories, such as the ‘stages of change’ model6. Incidentally, these theories do not exist in competing or water tight compartments. Many have similar or overlapping elements. One of the theories receiving a lot of current attention is so-called ‘nudge’ theory7,8. I am a very strong supporter of this theory, from both philosophical and psychological points of view, as follows:

  1. Philosophically, this theory makes a lot of sense. It is not illiberal (unlike very high taxation or prohibitions) and recognises human autonomy. In short, it is not coercive. However, it does seek to help people promote their own long-term aims, and overcome short-term impulses. In other words, it seeks to support people when they try to maximise their long-term objectives but succumb to short-term gratification. This philosophical idea is predicated on the notion that there really is a difference between these two things – long-term objectives and short-term gains and that a person can freely choose to place limits on their future options.
  2. This is where modern psychological theory comes in. Traditionally, psychologists have held the view that the acid test of a person’s preferences is their expressed behaviour. If you really want to know what a person thinks about something then their behaviour is the most reliable test – a tenet of behaviourism. However, this does not conform with modern neurophysiology. For instance, it has been found that there are two circuits, one governing desire and the other governing gratification. These are only weakly linked9.

It thus seems both philosophically and psychologically entirely cogent to argue that people have two different kinds of motivation which may be in conflict – their long-term aims and desire for short-term gratification. In short, simply yielding to temptation is not tantamount to expressing an ‘overriding’ or ‘genuine’ preference. No, the brain is modular and can quite easily hold two contradictory beliefs at the same time. In fact, Homer anticipated all this, with the story of Odysseus, who had himself lashed to the mast so that he would not be able to destroy his boat in a desperate lunge to requite his desire for the sirens.

My own University of Birmingham is planning to collaborate with Professor Nick Chater’s group of behavioural psychology, at the Warwick Business School, in taking these ideas forward. We are forging links with the local authorities, both here in Birmingham and in Coventry, so that we can add to the scientific basis for behaviour change.

References

1. Hughes JR, Keely J, Naud S. Shape of the relapse curve and long-term abstinence among untreated smokers. Addiction.2004;99(1):29-38

2. LaFaive MD, Nesbit T. Higher Cigarette Taxes Create Lucrative, Dangerous Black Market. http://www.mackinac.org/18128 (accessed 26 April 2013).

3. Anderson JW, Konz EC, Frederich RC, Wood CL. Long-term weight-loss maintenance: a meta-analysis of US studies. The American Journal of Clinical Nutrition.2001;74(5):579-584

4. Teixeira PJ, Silva MN, Mata J, Palmeira AL, Markland D. Motivation, self-determination, and long-term weight control. Int J Behav Nutr Phys Act .2012;9(22):1-13

5. Bader P, Boisclair D, Ferrence R. Effects of Tobacco Taxation and Pricing on Smoking Behavior in High Risk Populations: A Knowledge Synthesis. Int. J. Environ. Res. Public Health.2011;(8):4118-4139

6. Prochaska JO, DiClemente CC. Stages and processes of self-change of smoking: Toward an integrative model of change. Journal of Consulting and Clinical Psychology. 1983;51(3):390-395.

7. Thaler R, Sunstein C. Nudge: Improving Decisions About Health, Wealth and Happiness. 1st ed. London. Penguin Books; 2009

8. Nick Chater. Lessons in Nudge Marketing: Wy nudges work… and why they don’t. http://portal.sliderocket.com/ACXHL/Nudge-Marketing-Event-07-07-2011 (accessed 26 April 2013).

9. Bauer M. How to Avoid the Temptations of Immediate Gratification. http://www.scientificamerican.com/article.cfm?id=how-to-avoid-the-temptations-of-immediate-gratification (accessed 23 April 2013).

Advertisements

Who will look after the patients when all the doctors have been locked up?

Professionals, doctors included, live in an increasingly regulated environment: not only is performance monitored on a regular basis, but doctors are subject to individual sanction. They may be scrutinised by the complaints procedure in the health service, they may be taken to the regulator (the General Medical Council), and they may be sued in the civilian courts under tort. On top of all this, they are subject to criminal prosecution.

Criminal prosecution implies a criminal act, and of course doctors should not be immune from prosecution for criminality, including crime perpetrated in the workplace. There was a famous case where a French anaesthetist sought revenge on a colleague by misconnecting the gas pipes in the operating theatre. The idea was that his colleague would be sanctioned for harm to a patient, but the ruse backfired and the guilty anaesthetist was quite properly locked up.

But what about acts of misjudgement? That is, acts where there is no question of criminal intent. The law, of course, does not require criminal intent for a deed to be punishable. For example, a drunk driver may still go to jail for running over a pedestrian even though he never set out to cause harm. The point here is that, by driving under the influence of alcohol, others were placed in harm’s way. The equivalent in healthcare would be criminal negligence – negligence so gross that harm could be foreseen, even if the specific harm that materialised was not intended. Thus, a doctor who operates drunk, or against the clock, can properly be found criminally negligent if a patient suffers. Things get more tricky, however, when there is no such turpitude – when there was simply a terrible mistake. It is quite difficult to argue this point in abstract so let us take a real example. I have heard of two cases where criminal prosecutions were started against a doctor when a patient, having been declared fit in accident and emergency, then died from heart attack on the way home. Yet, the diagnosis of heart attack is notoriously tricky in many cases. While it might seem to a lay person that there is a prima facie case of criminal negligence in such a scenario, this is most unlikely to withstand scrutiny. In cases above, prosecutions were not brought in the end. Nevertheless, doctors were suspended and lived under a cloud for many years. Having a criminal case hanging over you is no joke.

It seems to me that the criminal code should not be invoked in the first instance, unless there is some reason to believe there was real criminal intent, or that the clinicians had risked a patient’s safety by working in a general way which put patients at risk. My proposal is that more contentious cases should first be pursued through regulatory or civil processes. Only if these expose negligence to a criminal degree should the prosecution service get involved.

Of course it is not just doctors and other clinicians who are in the firing line; professionals of all types may be prosecuted. A recent case applied to six seismologists from the National Commission for the Forecast and Prevention of Major Risks (Franco Barberi, Enzo Boschi, Gianmichele Calvi, Mauro Dolce, Claudio Eva and Giulio Selvaggi) and the vice director of Italy’s Civil Protection Agency (Bernadro Bernardis) who have been sentenced to six years in prison in a criminal court for failing to provide adequate warning about a potential earthquake. In the event, a large earthquake followed, resulting in approximately 300 deaths, 1,500 injuries and left over 65,000 homeless, and the judge found that some people’s lives might have been saved, had a stronger warning been given.1 In fact, the judge in this case gave a harsher sentence than the prosecutor had requested (four years).2 Here is a case which was prosecuted in the criminal courts and where the accused were found guilty. Such a case is at enormous risk of hindsight bias. Predicting earthquakes is extremely tricky. Finding the right form of words to convey this uncertain risk is also extremely difficult. I have to confess sympathy with the convicted seismologists. They are currently appealing their harsh sentences, and it will be interesting to see if the appeal judge agrees.

Returning to healthcare, criminal prosecutions have escalated since the 1990s but convictions seldom follow.3 Misdiagnosis, the most important medical ‘error’, and the most common cause of civil litigation4 seldom forms the basis of prosecution, less a successful prosecution.

Robert Francis’ report has been interpreted in the media as saying: “Hospital staff and managers should face prosecution if patients are harmed or killed as a result of poor care”5 and indeed the report says: “Non-compliance with a fundamental standard leading to death or serious harm of a patient should be capable of being prosecuted as a criminal offence, unless the provider or individual concerned can show that it was not reasonably practical to avoid this. Reliance might be placed for that purpose on effective implementation of the procedures devised by NICE, but this would offer no defence to those who had not followed such a procedure.”6

So if you don’t follow a process laid down by the National Institute for Health and Clinical Excellence (NICE), then the criminal law can be invoked. This seems a high standard indeed given evidence on uptake of guidelines.7,8 The recommendation will need to be thought through rather carefully, I think.

References
1. Nature (2011). Scientists on trial: At fault? 14 Sep 2011. Available at: http://www.nature.com/news/2011/110914/full/477264a.html [Accessed 7 Feb 2013].

2. Nature (2012b). Italian court finds seismologists guilty of manslaughter. 22 Oct 2012. Available at: http://www.nature.com/news/italian-court-finds-seismologists-guilty-of-manslaughter-1.11640 [Accessed 7 Feb 2013].

3. Ferner RE, McDowell E. Doctors charged with manslaughter in the course of medical practice, 1795 – 2005: a literature review. J R Soc Med. 2006;99:309-314

4. Ferner RE. Medication errors that have led to manslaughter charges. BMJ. 2000;321:1212-1216

5. Guardian. Mid Staff report calls for sweeping changes to improve patient safety. http://www.guardian.co.uk/society/2013/feb/06/mid-staffordshire-report-sweeing-changes (accessed 7 Feb 2013).

6. Francis R. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry Executive Summary. http://cdn.midstaffspublicinquiry.com/sites/default/files/report/Executive%20summary.pdf (accessed 7 Feb 2013).

7. Benning A, Dixon-Woods M, Nwulu U, Ghaleb M, Dawson J, Barber N, Franklin BD, Girling A, Hemming K, Carmalt M, Rudge G, Naicker T, Kotecha A, Derrington MC, Lilford R. Multiple component patient safety intervention in English hospitals: controlled evaluation of second phase. BMJ. 2011;342:d199.

8. Asch SM, Kerr EA, Keesey J, Adams JL, Setodji CM, Malik S, McGlynn EA. N Engl J Med 2006; 354:1147-1156