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.’