Now that the Conservatives have enough MPs to form a government, they should seize the initiative to tackle some fundamental issues about public health. At the outset it is crucial to question much of the current thinking.
It is essential to appreciate that the present strategies are just not working. The incidence of Type 2 diabetes (T2D) has doubled in the past 15 years and is expected to continue increasing. The picture for obesity is somewhat similar. Although life expectancy has increased, more and more people suffer from conditions such as Alzheimer’s Disease which means that the costs of care are escalating.
Lack of resources is not the fundamental problem with the NHS. If we keep throwing money at the system, 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.
The prime objective of any national health policy ought to be to ensure that that the standards of public health are as high as possible. Unfortunately the politicians have allowed themselves to be influenced by vested interests which have succeeded in manipulating policy formulation so that they (the vested interests) actually benefit in a big way.
There is absolutely no doubt that enormous sums of money are being spent on drugs which are totally ineffective and many do more harm than good. An excellent example of this is “polypharmacy”, which is the prescription of multiple drugs, especially for elderly people. The new Minister for Health would do well to ask for hard evidence that the policy is effective. No doubt he/she would be surprised to learn that a study conducted in Israel evaluated the impact of reducing the medication in elderly patients in nursing homes (1). At the outset the average number of medications was just over 7. It was found that out of 190 it was possible to stop some drug usage in 119 of them so that the average usage was reduced by 2.8. The results showed that the mortality rate in the control group whose medication remained the same was 45% but in the study group whose medication was reduced the mortality rate was only 21%. Furthermore 30% of those in the control group had to be referred to hospital whereas only 11.8% of those in the study had to be referred. These figures are absolutely staggering and have been confirmed repeatedly by other workers. Above all, the results demonstrate conclusively the damage to the individual patients that is caused by the excessive use of drugs. There really can be no other explanation.
In his excellent book “Doctoring Data”, Dr Malcolm Kendrick is critical of the Quality Outcome Framework (QoF) because it provides guidelines on “risk factors” which have to be measured and used as a basis for prescribing drugs as a preventative treatment (2). In his experience this has resulted in patients with an average number of medications of 10. This is much higher than in those patients involved in the research described above. The only way to prove that a specific combination will be effective is to conduct thorough trials which are designed to find out the benefits and assess the adverse side-effects. This has certainly never been done and is pretty well impossible to do because of the number of possible combinations is infinite. Even for a limited number of trials, the expense would be enormous and realistically will never be made available. However before we get to that point there is simply no reasonable justification for such a programme. The reality is that many of the drugs which are widely used can hardly be justified in their own right let alone in combination with others. Despite all the hype the benefits of statin use are minimal. When the latest NICE recommendations were being announced, the spokesman Mark Baker accepted that 77 people with previous heart problems would have to be treated for 3 years in order that one would benefit. And what exactly is the benefit…an extra 6 months of life (thanks again to Malcom Kendrick, 3). Then there are the adverse side-effects such as the aches and pains which seem to affect most of those I know who have been on statins. Some unfortunates suffer cognitive impairment. It is now becoming apparent that statins can substantially increase the risks of developing Type 2 Diabetes. For men without any heart issues and for all women there is no convincing evidence that there will be any reduction in mortality but of course these people will still experience the same incidence of adverse effects.
The more I discover about drugs and the way they are being used the less convinced I am of their value. No doubt there are some drugs which are effective but there is absolutely no doubt many drugs have no benefit whatsoever. The NNT (Number Needed to Treat) website (4) is an excellent source of reliable information on the effectiveness of various drugs. Consideration of those dealing with heart conditions shows that for about half of them the evaluation was that “none would helped”. When there is a benefit it is limited to relatively few people….a particularly good one would be for 10% of those treated to be helped. In my experience, most people would expect that there would be some benefit as a result of a drug treatment. If the chances of success were as little as 10% which has to be set off against any harmful effects, how many would agree to the treatment if this information was spelled out before any decision on medication was taken?
But there is not only excessive use of drugs.
In 2010, Dr Atul Gawande was named by Time magazine as one of the world’s influential thinkers.
In one of his Reith lectures last year he described a comparison he made between the medical facilities in 2 Texas communities (5). One was McAllen and the other was El Paso County. Both of these counties have a population of roughly seven hundred thousand, similar public-health statistics, and similar percentages of non-English speakers, illegal immigrants, and the unemployed. Yet in 2006, Medicare expenditures which is the best approximation of the costs of health care in El Paso was $7,504 per enrollee—half as much as in McAllen (6). There was no evidence to indicate that the treatments and technologies available at McAllen were any better than those found elsewhere in the country. The annual reports that hospitals file with Medicare show that those in McAllen and El Paso offer comparable technologies—neonatal intensive-care units, advanced cardiac services, PET scans, and so on. Public statistics show no difference in the supply of doctors. In fact Mc Allen actually has fewer specialists than the national average.
Dr Gawande eventually gained access to commercial insurance data which revealed that compared with patients in El Paso and the country as a whole, patients in McAllen were given more diagnostic testing, more hospital treatment, more surgery and more home care. More detailed information was obtained from Medicare payment data. This showed that between 2001 and 2005, critically ill patients received almost fifty per cent more specialist visits in McAllen than in El Paso, and were two-thirds more likely to see ten or more specialists in a six-month period. In 2005 and 2006, patients in McAllen received 20% more abdominal ultrasounds, 30% more bone-density studies, 60% more stress tests with echocardiography, 200% cent more nerve-conduction studies to diagnose carpal-tunnel syndrome, and 530% more urine-flow studies to diagnose prostate troubles. They received one-fifth to two-thirds more gallbladder operations, knee replacements, breast biopsies, and bladder scopes. They also received two to three times as many pacemakers, implantable defibrillators, cardiac-bypass operations, carotid endarterectomies, and coronary-artery stents. And Medicare paid for five times as many home-nurse visits. So Dr Gawande had absolutely no doubt that the primary cause of McAllen’s extreme costs was, very simply, the across-the-board overuse of medicine.
All of this shows unequivocally that enormous sums of money are being wasted in health treatments that are useless and in many cases do more harm than good.
If the new Minister is to do the job properly then he/she must make it a priority to ensure that all expenditure on treatment and diagnostic procedures is justified on the grounds that it makes a significant contribution to improvements in health and that any adverse effects are definitely outweighed by the benefits.
I find it particularly galling that soon after the results of the UK General Election were announced the former Minister of Health, Jeremy Hunt, was still talking about putting more money into the NHS.
It is blindingly obvious that a new approach is essential. The new Minister will have to exert control right from the beginning otherwise the existing apparatus of advisers and agencies will ensure that things carry on as before. There are many individuals the Minister could invite who are independent of vested interests and have the authority and expertise to provide the necessary input.
I have already mentioned Dr Atul Gawande and Dr Malcolm Kendrick who would be ideal. Other suggestions could be:
- Dr Peter Gøtzsche, Professor of Clinical Research and Design Analysis at the University of Copenhagen
- Dr Tim Noakes, emeritus professor of Sports Science at the University of Cape Town
- Dr Richard Smith, Former editor-in-chief of the BMJ (British Medical Journal).
While there are very powerful interests that will fight tooth and nail to maintain the status quo, the political rewards for the person who can devise and implement a cost-effective strategy that results in significant improvements in health are immense. Can David Cameron find anyone with the capability of achieving these objectives to take on the Health portfolio?
REFERENCES
- D Garfinkel et al (2007) Israel Medical Association Journal 9 (6) pp430-434
- M Kendrick (2014) “Doctoring Data: how to sort out medical advice from medical nonsense”. Columbus
- http://drmalcolmkendrick.org/2014/12/01/what-is-t/
- http://www.thennt.com/home-nnt/
- http://downloads.bbc.co.uk/radio4/open-book/2014_reith_lecture3_edinburgh.pdf
- http://www.newyorker.com/magazine/2009/06/01/the-cost-conundrum?currentPage=all