Less is more: How to save the NHS. Spend less on unnecessary drugs

By Jerome Burne

Here’s a radical idea. Why not use drugs for cases where they are appropriate, safe and effective. And don’t use them when they aren’t. Wild eh! It’s an idea that could save the NHS billions. Three clinicians I know are thinking along exactly these lines.

First up on the witness stand is Dr Aseem Malhotra, heroic campaigner for sensible medicine, whose article in BMJ last week announced the launch of a new UK campaign: “to reduce the harms of too much medicine.’ It’s a move that started in the USA to promote more of a two-way conversation between doctors and patients. Patients are encouraged to ask if tests are really needed while doctors should discuss the potential harms of treatments. (http://www.bmj.com/content/350/bmj.h2308)

Malhotra and the other authors identify a medical culture that results in patients being offered treatments that have only minor benefit and minimal evidence, despite the potential for substantial harm and expense. ‘Sometimes doing nothing can be the best approach,’ says Dr Malhotra. It could also save money.

That’s obviously badly needed with the NHS facing a spending gap estimated to be between 3 billion and 8 billion. Drugs cost the NHS around 15 billion a year so how much of a saving might result from a wider rethink on the way we use drugs?

How to save five billion

Taking prevention and lifestyle changes seriously, rather than reflexively relying on drugs to keep us healthy, could significantly narrow the gap .We have a ballooning and increasingly expensive population of sick people – one in six over 40 have diabetes, one in three over 50 are obese and one in four over 80. A properly funded campaign to keep them healthy for longer could produce a saving of five billion pounds, according to calculations based on official sources by my friend Patrick Holford.

A prevention drive is a no brainer and yet prevention the Cinderella of health care. In Alzheimer’s, for instance , even though experts all agree that life-style contributes around 50% to the risk, the amount spent on researching it is pitiful. In seven years between 2006 and 2013 just 0.11% of the government’s dementia research budget was spent on prevention research: £156,000 out of £140 million.

So to cut NHS costs what’s needed is to spend more on research and to begin implementing what we already know. Holford’s blog sets out a five point plan which I’m not going to repeat but here are a couple of highlights.

The first step to fund the the necessary changes is a sugar tax. Set at 20% this could generate 2 billion pounds on products that delivered more than 10% of their calories from sugar. Another billion could come from putting a 20p tax per litre on sugar-sweetened drinks. Combined with an education campaign, this would start producing savings as sugar consumption declined, reducing obesity and its associated costs.

How to cut the bill for Alzheimer’s

Some of the funds from the tax could go to implementing what we already know about ways to cut the rising bill for Alzheimer’s. First off would be to fund a follow up to the research showing the benefit of reducing blood levels of the amino acid homocysteine with high dose B vitamins.

(An appallingly done meta-analysis claims to show this doesn’t work but that’s a topic for a later post.)

Research published only a month ago has now tied omega 3 into the picture. For the B vitamins to work you need good levels of these fatty acids.

Just delivering the B vitamins plus healthy levels of omega 3 to all those at raised risk, who can be identified, could reasonably be expected to produce one billion pounds in savings.

A similar saving of a billion could come from implementing what is already known about treating and reversing diabetes with diets that significantly reduce the carbohydrate intake so lowering glucose in the blood, the substance that diabetics are having problems handling. Why on earth wouldn’t you do that? (see posts on the low carb diet on this site for details). Reducing the number of new cases this way by just 20% would give you the billion pound saving.

Diabetes drugs to keep down the blood glucose pushed up by the recommended diet, now cost the NHS over 800 million. As if that wasn’t daft enough some of the diabetes drugs let loose on the market at high prices seem to have nothing to recommend them at all. Take one called Saxagliptin. Last month a large trial found that it didn’t reduce patients’ risk of having a heart attack, although the good news was that it didn’t damage the heart.

Drugs that may raise risk of pancreas damage 20 times

Since heart attacks are a major risk factor for diabetics you might think that this would be enough to have it withdrawn, especially since experts have long been worried about its safety – it’s one of a class known as DPP4 inhibitors which have been linked with causing damage to the pancreas – one study found they could raise the risk 20 times.

But no, the FDA committee assessing it voted almost unanimously that its risk profile was “acceptable”. And that wasn’t the only bit of evidence from this report showing that he bar for drug approval is set so low that a cost cutting trawl through the total drugs budget should be able to find acres of not just dead wood but positive dangerous timber as well.

A passing comment in the report of the FDA’s deliberations threw doubt on the long term benefit of diabetic drugs in general. Their main job is to bring down glucose in the blood – the marker for this is something called HbA1c. So you’d assume that low HbA1C kept you healthier. However a casual comment by one of the experts on the committee suggested that might be largely a waste of time.

“The diabetic community needs to demonstrate that lowering HbA1c is beneficial,” he said. To which the author of the report – a senior columnist on Forbes magazine – added: ‘No one expects a prompt solution to that problem.’

“Less is more” policy to save the elderly

So we are facing a future filled with unnecessary treatments and drugs whose harm may outweigh benefits, which in turn may be even smaller than anyone suspected. It is hardly surprising then that a few physicians who are not afraid to challenge the status quo are exploring the idea that rather than writing ever more prescriptions, doctors should be handing out fewer.

And there is no area of medicine more in need of a “less is more” policy than in what’s known as polypharmacy – a way of describing the fate of millions of elderly people who, with inexorable logic, are given more and more expensive drugs as they develop more and more age-associated disorders – high blood pressure, weight gain, joint pain and so on. The diagnosis of each comes with treatment guidelines involving two or three more pills. Soon you are on drug cocktails that have never been tested in any controlled trial and which are guaranteed to raise your risk of side effects.

So I was delighted to receive an email from Dr David Unwin, one of HealthInsightUk’s contributors, saying that he too was concentrating on cutting drug use. Quite independently his ideas echoed not only Dr Malhotra’s call for less medicine but also for greater use of prevention by helping patients make life-style changes.

‘At present I am becoming interested in the new verb: to Deprescribe – To stop prescribing unnecessary medications currently on repeat prescription,’ he wrote.’ So often we docs just add in more medications as the years go by, so that for many elderly patients polypharmacy is a real problem.

Yet more unnecessary pills

‘It seems to take more time and energy to stop medications than to start them. Even so surely this represents a possible gold mine of wasted money -if only we could be resourced and motivated to investigate its possibilities.

‘For instance, almost every week I see an elderly patient who suffers from over-treatment of their blood pressure. If they stand up too fast they go dizzy and are at risk of falls A few weeks ago I called three ambulances in as many days because of it!

‘Part of the problem is ‘White coat hypertension’ – a description for what happens when, because of anxiety caused by having the blood pressure measured, it is significantly higher than it  would be when they were relaxed at home. The result is often more unnecessary pills.

‘But polypharmacy isn’t just the result of unnecessary pills, it could also be reduced dramatically if we took lifestyle improvements seriously BEFORE starting lifelong medications.

‘As an example of the benefits that can bring, for the past two years I have given all type 2 diabetics the option of a two month weight loss programme as an alternative to the standard diabetes drug metformin The offer has been accepted by all my patients without exception and the result has been an average weight loss of approximately 10 kg. Many of them have been able to come off their drugs rather than having to stay on them for life.’ 

Jerome Burne

Jerome Burne

Jerome Burne is the editor of HealthInsightUK. He is an award-winning journalist who has been specialising in medicine and health for the last 10 years and now works mainly for the Daily Mail. His most recent book “10 Secrets of Healthy Ageing” was written with nutritionist Patrick Holford. He blogs at “Body of Evidence” – jeromeburne.com. 2015: Finalist for 'Blogger of the Year' award from Medical Journalists' Association.

10 Comments

  • It’s not just unnecessary pills but unnecessary vaccines. How much do these cost the state? This year’s flu vaccine was ’3% effective’ according to Public Health England. So, for 97% it was a waste of time. GPs are remunerated to vaccinate so that’s extra cost to the NHS too.Self-administering vitamin C is much more effective. (46% symptom free in 24 hours with 8 grams in first 24 hours of infection.) Does anyone know the true costs of vaccinations and their NNT both for harm and benefit – aka HPV? These figures are hard to come by, as are the out of court settlements of cases involving adverse vaccine reactions – another cost-saving area. GSK’s new chief,Sir Philip Hampton, formerly of RBS,has a plan ‘to beef up vaccines while reducing GSK’s dependence on selling high-priced drugs to the developed world’ to fix the ‘ailing business’ that has been part crippled by fines for dishonest marketing, hiding adverse effects and encouraging off-label prescribing. So, we can expect more vaccine sales.

  • I’m absolutely with you. I read an article by a Doctor on the web, I forget by whom sadly, but he used the term “watchful waiting”, before prescribing!! So many non life-threatening conditions will clear up on their own, of course it may take longer, but without pills and side effects and then more pills to counter the side effects etc etc…… Nutrition should be the first line of preventative medicine – with the correct nutritional advice of course. Have you seen the latest headlines from the AND? http://www.eatrightpro.org/resource/news-center/on-the-pulse-of-public-policy/from-the-hill/academy-submits-2015-dga-recommendations
    They support the new dietary guidelines to stop recommending reducing dietary cholesterol but amazingly also recommend dropping sat fats and salt from the nutrients of concern list too – at last!! Fantastic news – let’s hope the UK follows this lead soon. Once the correct dietary advice is in place, and is followed, we will all benefit from improved health and a smaller NHS bill ultimately. We are truly on the edge of a wellness renaissance.

  • “A prevention drive is a no brainer”: preventive medicine as a panacea is probably mainly wishful thinking. Just think of those mass screening policies which are undoubtedly expensive but of doubtful medical value.

    • Editorial

      Dearieme indeed. Those mass screening policies have certainly been totally ineffective according to a recent report on effectiveness of programs to encourage GPs to do more screenings. The reason is that their aim was to get more people onto drugs, in which they have been very successful. More testing plus regular lowering of the “healthy” level for the likes of cholesterol and blood pressure has boosted sales marvelously.

      But that only proves that trying to prevent chronic disorders with drugs, is an very expensive and very ineffective way to do it. It has nothing to say about prevention which involves changing lifestyle in a healthier direction. It is perfectly obvious that many foods can made us ill and it is indeed a no-brainer to suggest that the right ones can keep us healthier.

  • But governments have been issuing propaganda for forty years or more about healthy eating, almost all of it wrong-headed and pernicious. How do you know that whatever new propaganda is introduced will be any better?

    • Editorial

      Absolutely agree but the dietitians’ close relationship with big sugar and big processed foods – see recent article here on HIUK on “cuddly dietitians – has been a major obstacle to an an effective program. Also not helpful is the fact that doctors have almost no education in nutrition and the overall spend on researching prevention as compared with the drugs needed when the damage is done, is pitiful. See near zero funding for research into Alzheimer’s prevention.

  • Is there much evidence of the effectiveness of government health propaganda beyond “wash your hands”, “stop smoking”, “get your vaccinations” and a very few others?

  • When you say “one in six people over 40 have diabetes”, what exactly do you mean? How are you defining diabetes? It seems very high and now I’m always suspicious of these statistics. Has diabetes been redefined recently? Aren’t there now many borderline cases which could be resolved with a moderate change of diet?

  • dear Jonathan I have been doing a lot of research in regards to this topic of statistics for health markers. there is a book you might want to look for and its called selling sickness how the large pharmaceutical companies are making patients of all of us. how this happens is that over the last 50 years there has been channels to determine health markers. These markers determine when it becomes necessary to take medicine for it. I remember distinctly in the late 70′s early 80′s hearing that normal blood pressure was 100 plus your age. now everyone regardless of age needs to have a blood pressure of a hundred and fifteen. medicating blood pressure to this level causes a lot of senior citizens to faint fall break bones etc. and regards to diabetic numbers I have read that a fasting blood sugar of below 200 I meant you were fine and did not need medication. now it has to be under 100 or else your doctor will prescribe medication and make you feel that if you don’t take this medication you are endangering your health. also know bad many heart medications destroy your body’s ability to metabolise sugar so your blood sugar numbers go off go up.

  • Dear Jonathan. also Jonathan most of the doctors on the panels to make these decisions from what I’ve read tend to have direct financial ties to the pharmaceutical companies that produce the remedy when threshold numbers for treatment are lowered. I think you’re on the right track.

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