It’s impossible not to notice the debate around intersectionality which feminists are having on and  offline. An example; being concerned about domestic violence means also being concerned about poverty, sexuality and mental health. As wikipedia puts it; it’s “the study of intersections between different disenfranchised groups or groups of minorities; specifically, the study of the interactions of multiple systems of oppression or discrimination….The theory suggests that – and seeks to examine how – various biological, social and cultural categories such as gender, race, class, ability, sexual orientation and other axes of identity interact on multiple and often simultaneous levels, contributing to systemic social inequality.”

A few weeks ago I had a disconcerting set of interactions on an internet forum. A doctor expressed his annoyance at my campaigning against the RCGP publication ‘Emma’s Diary’ – which I object to because it contains screeds of adverts – because, he said, there are far more important threats to the NHS and general practice.

In some ways I can see the point. The Health Act is a disaster for patients, and general practice is under threat by companies who seek to hive off the bits they think are capable of making a profit. But Emma’s Diary is part of this same structural social inequality. The College profits from the magazine because of the adverts. The adverts are for many expensive things which parents don’t need; adverts given out by a doctor lend the magazine an air of approval. Some parents will ignore it. Some will feel guilt that they cannot afford much; others will buy things when their money would be better spent elsewhere. The RCOG produce a similar free magazine aimed at pregnant women. In the  piece for the BMJ I explained how a company chairman was told he could become a ‘thought leader’ on infant sleep for payment of 15K’s worth of adverts. The ‘thought leader’ culture in pharma is well established. Pharma has been often guilty of misleading medical evidence via advertising, and many medical trials go unpublished, which increases the risk of patients and doctors being badly informed about treatments. Again, the medical stamp of approval can be meaningless, and has the capacity to mislead.

Unfair information about healthcare is an important cause of avoidable harm. Patient autonomy becomes void if the information the patient gets to help make choices are based on exaggerated benefit or risk, or are incomplete. Social justice means that patients should be treated equally; yet without equal access to fair information about choices, we fail.  So when it comes to screening, people should be given open and transparent information about the chance of benefit and of harm, rather than being told what they ‘should’ do. It is the same concern for the primacy of the patient which means that research should be done with the purpose of finding out what is useful for the outcomes which matter to patients, rather than proxy markers from drug companies. It is that same need to consider the patient and her need for social justice which means that the consultation should be about the patients needs, not the identification of risk factors which the GP contract encourages us to do.

All my fury and passion about the state of medicine is intersectional; it’s part of the whole. I can’t be concerned about a bunch of RCGP approved adverts in Emma’s Diary without also being concerned about the misinformation used to advertise private health screenings. The adverts compete for attention and money, using little evidence to do so. The same underlying principle makes me realise that competition which the Health Act has created will use the same system of adverts, and gives rise to the problem whereby well people are damaged by interventions they don’t need, while sick people don’t get the timely care they do need. Concerned about overdiagnosis and overtreatment as a harm of healthcare is part of the same parcel; it also means that the principle of doctors accepting gifts, either from pharma or via contracts from PR companies reflects this.

The removal of Emma’s Diary from the hold of the RCGP and the removal of the commercial Bounty representatives from postnatal wards (again, related, intersected) are part of the whole. How easy – or hard – will it be to take out a financial conflict of interest from the NHS? How difficult will it be to persuade the RCGP that the best information is unbiased and free of conflicts of interest? When people say they don’t want to be hassled by reps selling things at a vulnerable time, how clearly can this be translated into the NHS?

I think the nature of these interlocked, emeshed, tangled questions, priorities and conflicts is such that in talking about one, we talk about them all; what am I doing? and who is it for?