121. Time for a Reality Check on the NHS

According to a report in The Guardian:

“The NHS is generally acknowledged to be facing a growing funding crisis after four years of tight settlements, deepening demographic pressure and an inefficient system that splits health and social care. The Nuffield Trust has suggested there will be a financial shortfall of £2bn in 2015-16” (1).

The politicians are desperately trying to overcome the problems by finding more money.

The critical feature is that there is an almost total failure to conduct any kind of hard-nosed analysis to identify the fundamental issues and devise suitable objectives for the NHS. We have to face the reality that health is deteriorating as shown, for example, by the doubling of diabetes, primarily Type 2(T2D) in the past 15 years. The number of people who require care and nursing is growing steadily. It is therefore no surprise that the costs continue to increase. Clearly this is not sustainable in the long term. If we carry on in this way we will finish up like the USA which spends more than twice the amount on health care per capita as other developed nations, but ranks 49th in life expectancy worldwide.

Instead of accepting that there is a need for additional funds the politicians should be trying to determine what should be done to prevent standards of public health getting worse and working out how to reverse current trends so that a steady improvement can be achieved. Conceptually this is not difficult. The current approach is primarily “curative”. Unfortunately a cure is impossible in the vast majority of cases and the best that can be done is to “manage” the condition or disease. The obvious answer therefore is to place much more emphasis on preventing the disease in the first place.

So why have we come so far down the wrong road? To understand this we have to consider the role of the drug companies. Most of us have been conditioned or “brain washed” into believing that there should be a “cure” for every possible form of ill-health we experience. Even if one is not available at present all we have to do is pour money into research and eventually the scientists will come up with a remedy. While this may work for a number of diseases (eg antibiotics and certain infections) it is definitely not the answer for all diseases. With many of them the damage is permanent. For others, a “cure” may be possible in the short term but if the primary cause (eg exposure to toxins or poor diet) is not removed then the likelihood is that disease will re-cur.

Any analysis of the current difficulties of the NHS must examine the role of the
drug companies. The expenditure on drugs by the NHS is about £14B, which is almost 10% of the total budget (2). It is vital to appreciate that for many of the drugs being prescribed, there is no reliable evidence to demonstrate that they are effective. Quite the contrary, many of them are ineffective. One way of assessing this is to determine the NNT (Number Needed to Treat), which is the number of people who have to be treated in order that one will benefit. This may come as a surprise to many who quite naturally assume that if they have treatment with a drug it will almost certainly help them to recover. However if the NNT is 10 it mean there is a 10% chance of benefit and with an NNT of 100, then there is only a1% chance. Some examples from the NNT website, which only uses high quality studies in its analyses, are shown in Table 1(3). I believe most people would be absolutely astounded to see these results. The normal expectation is that any treatment will have a positive effect for the individual involved. This is certainly true of antibiotics so it somewhat disconcerting to learn that there is only a 1 in 4 chance that the treatment will prevent a respiratory tract infection. However for other treatments the odds of success are even smaller. With thrombolytics for a major heart attack, only 1 in 43 benefits and even then that is dependent on the treatment being applied within 6 hours. The results are even worse if treatment is delayed. Furthermore there were some risks that serious harm could also occur. Despite all the hype it turns out that the NNT team only find benefits for statin treatment in those with known heart disease even then it only applies to 1 patient out of 83. However the risks of developing diabetes are 1 in 50 while 1 in 10 may expect muscle damage. It seems highly likely that perceptions of the benefits of drug treatments are very much greater than the reality. It would be fascinating to discover how many people would agree to these treatments if they were informed of the chances of personal benefit beforehand. Even more astounding is the revelation that although some drugs have limited benefits for some conditions, when used for others there is no benefit whatsoever and in many cases those treated suffer adverse side-effects. This is appalling. It is quite obvious that the benefits of drug use have been grossly exaggerated. Hence it follows that most of the money spent by the NHS and any other body/individual on drugs is wasted. Effectively the pharmaceutical industry is sucking resources out of the system which could be spent in other ways that would facilitate patients. From a policy perspective, reducing expenditure on drugs by the NHS should be a top priority. Unfortunately there is no indication that any politician is aware of this information let alone prepared to tackle this issue head on.

TABLE 1. The Benefits and Harm Associated with Various Medical Treatments

Treatment	Benefits	Harm
Beta Blockers for Acute Heart Attack (Myocardial Infarction).	None were helped	1 in 91 were harmed by cardiogenic shock
Early Invasive Management for Acute Coronary Syndromes	None were helped (preventing death)1 in 9 were helped by feeling less pain in chest1 in 59 were helped by avoiding a heart attack in the next year	1 in 33 were harmed by suffering a heart attack.1 in 33 were harmed by suffered major bleeding
Anti-Hypertensive Treatment for the Primary Prevention of Cardiovascular Events In Mild Hypertension	None were helped (preventing death, stroke, heart disease, or cardiovascular events	1 in 12 were harmed (medication side effects and stopped the drug)
Statins Given for 5 Years for Heart Disease Prevention (With Known Heart Disease)	1 in 83 were helped (life saved)1 in 39 were helped (preventing non-fatal heart attack)1 in 125 were helped (preventing stroke)	1 in 50 were harmed (develop diabetes)1 in 10 were harmed (muscle damage)
Statins for Acute Coronary Syndrome	None were helped (life saved; heart attack, stroke, or heart failure prevented)	An unknown number were harmed (medication side effects/adverse reactions)
Statin Drugs Given for 5 Years for Heart Disease Prevention (Without Known Heart Disease)	None were helped (life saved)1 in 60 were helped (preventing heart attack)1 in 268 were helped (preventing stroke)	1 in 50 were harmed (develop diabetes)1 in 10 were harmed (muscle damage)
Blood Pressure Medicines for Five Years to Prevent Death, Heart Attacks, and Strokes	1 in 125 were helped (prevented death)1 in 67 were helped (prevented stroke)1 in 100 were helped (prevented heart attack)	1 in 10 were harmed (medication side effects, stopping the drug)
Thrombolytics Given for Major Heart Attack	1 in 43 were helped (life saved, given within 6 hours)1 in 63 were helped (life saved, given between 6-12 hours)1 in 200 were helped (life saved, given between 12-24 hours)	1 in 143 were harmed (major bleeding episode)1 in 250 were harmed (hemorrhagic stroke)
Thrombolytics for Acute Ischemic Stroke	None were helped (stroke symptoms improved)	1 in 20 were harmed (symptomatic intracranial hemorrhage)
Prophylactic Antibiotics for Reducing ICU Respiratory Tract Infections and Mortality in Adults	1 in 18 were helped (life saved)1 in 4 were helped (prevented one respiratory tract infection)	An unknown number were harmed (medication side effects/adverse reactions)

Once the limitations of drugs are appreciated it follows that we have to accept that many diseases cannot be cured. Whilst some alleviation may be possible, the reality is that if these diseases are to be overcome, the only effective strategy is prevention. Essentially this means lifestyle. In this blog I will focus primarily on diet because there is now overwhelming evidence that it does play a critical role in determining an individual’s personal health. This brings us up against another fundamental difficulty which is that much of the official advice is fundamentally wrong and has therefore been a crucial factor contributing to many of our common health problems.

There are convincing reasons why T2D, not obesity, should be regarded as the indicator of public health status. During 2013-2014 there were 45.1 million items prescribed for diabetes, with a net ingredient cost of £803.1million (4). This represents an increase of 66.5% in the number of items and 56.3% in the net ingredient cost since 2005-2006. In England it is estimated that 6% of the population has diabetes and the total cost is currently about £10billion (5). It is estimated that by 2025 there will be 5 million people with diabetes in England (6). Those with diabetes have a reduced life expectancy and an increased risk of retinopathy, stroke, kidney failure, heart disease and amputation of limbs.

A man diagnosed with T2D at age 40 will lose almost 12 years of life and 19 Quality Adjusted Life Years (QALYs) compared with a person without diabetes. A woman of the same age will lose about 14 years of life and 22 QALYs (7). Despite the huge expenditure on drugs, there are serious questions about the effectiveness of treatments of T2D to lower the blood glucose. In a meta-analysis of data from 13 randomized controlled trials there was no benefit, in adults with T2D, from intensive glucose lowering in terms of all-cause mortality or deaths from cardiovascular disease (8). Furthermore, an increase in all-cause mortality of 19% cannot be ruled out. Only one study showed a protective effect on myocardial infarction but this was counterbalanced by an increase in total mortality. The authors pointed out that drugs for the treatment of diabetes are being approved on the basis of their effectiveness in lowering blood glucose, despite the fact that there is no evidence based on clinically relevant criteria. It all adds up to more evidence about the misplaced confidence in the use of drugs to cure many diseases.

There is ample evidence that T2D can be controlled, possibly even cured completely by making changes to the diet (9). The condition is directly due to the increased level of glucose in the blood. As a result the pancreas has to produce insulin to prevent excess glucose in the body. Excessive insulin damages many of the organs, which can eventually lead to a range of diseases. If there is too much glucose over a prolonged period the pancreas is unable to cope and the glucose becomes rampant, causing all sorts of damage. The solution is obvious. Reduce the amount of glucose which enters the body by altering the diet. Sugar is one of the main culprits, so it should be avoided like the plague. In addition starch is broken down to produce glucose. This means that foods such as refined flour, rice or pasta should be limited because the starch is released quickly giving rise to big increases in the blood glucose.

Essentially this means a diet which is low in carbohydrates (LC). The big problem is that the official advice is to increase carbohydrates. There is a strong possibility that those diagnosed with T2D will be advised to replace fat with carbohydrates. This is fundamentally wrong! The recommendation to reduce fat and especially saturated fat (SFA) does not stand up to rigorous examination. In fact, many of the individual SFAs are important nutrients (10). So what we should be doing is limiting the carbohydrates and consuming plenty of fats

In order to make progress it is essential to alter the dietary advice. However this will not be easy. Although there is growing appreciation to limit sugar intake, the official advice from government and the NHS is to reduce fat. This means that those people who are genuinely attempting to consume a healthy diet will opt for low fat versions of dairy, meat and other types of food. Unfortunately this are usually formulated by removing the fat and replacing it with sugar and/or sweeteners. So the consumers are missing out on valuable nutrients and pushing up their intake of sugar. The official advice is to replace the fat with complex carbohydrates, such as wholemeal bread, potatoes, rice and pasta. All of these contain starch which is broken down to glucose, which inevitably raises the level of glucose in the blood. This approach is fully supported and promulgated by the vast majority of professional dietitians and nutritionists, who in any event feel compelled to comply with the official doctrine.

While recognizing the difficulties, it is the responsibility of the politicians to set the agenda and formulate policy objectives accordingly. Clearly it will mean that they have to take on very powerful vested interests, who will fight tooth and nail to maintain the status quo because they are doing very nicely. Politicians must be prepared to tackle bodies such as NICE which is “not fit for purpose” (11).

The current strategy is not working. Vast sums of public money are being wasted. Many people are suffering unnecessarily and dying prematurely. This is a huge challenge for the politicians. Are there any out there with the intellectual ability, determination and astuteness to address this issue?

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