In 2004 the UK introduced a pay-for-performance programme (Quality and Outcomes Framework-QOF) ostensibly to improve patient health care and outcomes and reduce the burden on the NHS, resulting in millions of UK citizens having to take a polypharmacy of drugs. As a result, GP income increased by 25%. However, rather shockingly, it hasn’t significantly reduced mortality rates for the chronic conditions it set out to target – instead inducing debilitating health issues in previously healthy people.
How can such a failure have gone so largely unnoticed until now? It’s increasingly obvious the more drugs prescribed, the sicker we’re becoming, compounding pressures on an already overloaded and failing health system.
Exposing the shortcomings of a system designed to improve healthcare, health journalist Jerome Burne sinks his jaws into the “biggest public health experiment ever”and it’s devastating consequences on public health as he reviews an explosive new book by Dr James Le Fanu “Too Many Pills: How Too Much Medicine is Endangering Our Health and What We can Do about it”. We publish extracts of Jerome’s latest article, published on 14 May 2018, on his blog HealthInsightUK below.
Over to Jerome:
By Jerome Burne, investigative health journalist and author, HealthInsightUK
The results of the largest ever trial testing the effectiveness and safety of using drugs to cut the risk of developing chronic diseases were published in the Lancet two years ago. They were astonishing and revealed a massive failure of a major plank in public health policy. Yet they have remained effectively secret.
Conducted in Britain, the trial ran for 15 years, cost 30 BILLION pounds and found no benefits. The expectation was that it would save around 10,000 lives a year, cut admissions to hospital and increase life expectancy. It didn’t do any of those.
What is even more remarkable (if not surprising) is that unless you are a medical professional or working in the NHS bureaucracy, it is very unlikely that you will have heard of it or what it found.
Actually, I have slightly misrepresented what was involved for effect. It wasn’t a proper trial, but it was certainly the largest-ever uncontrolled public health experiment which, irresponsibly and unscientifically, was done without being tested in a pilot. It wasn’t possible to have a control group because it was conducted on the entire UK population.
The data the report was based on is something known as QOF (Quality and Outcomes Framework) which was a system set up in 2004 that started paying GP’s for checking such biomarkers as blood glucose, triglycerides and cholesterol and then prescribing drugs to bring them down if they were over the official healthy level.
Too many drugs damaging our health
Dr James Le Fanu’s new book is about polypharmacy – prescribing an increasing number of drugs to most of us but to old people especially as they develop the conditions and disorders that are a common part of ageing.
The result is that by their 70’s many people are on 5 or more drugs. Most GPs agree it is a problem but, feel powerless to stop. It’s a direct result of the same approach to medicine that lay behind the QOF fiasco.
At the start QOF was perfectly logical, if untried. It was believed that many people had undiagnosed risk factors, such as too much blood sugar or ‘dangerously’ raised cholesterol, so encouraging GPs to test and treat would inevitably improve the health of the nation and cut costs by reducing the number of people numbers with diseases that needed expensive treatment. Wouldn’t it?
Creating a synthetic UK
Apparently not according to the analysis of the results published in the Lancet. Researchers from Michigan School of Public Health in the USA and from Manchester and York Universities in the UK gathered data on mortality and chronic disease in similar western countries without a medical pay-for-performance system.
Then they used that to create a ‘so-called synthetic UK as a weighted combination of comparison countries.’ The synthetic UK results were then compared with the result in the real UK and found almost no improvement.
Really? It was certainly very effective at increasing drug consumption.
More drugs and rising hospital admissions
About half the 30 billion spent on the experiment went on payments for the additional drugs. Meanwhile hospital admissions continued to rise. So, if the increased drug consumption wasn’t allowing people to live longer or stay out of hospital, what was it doing?
The whole project has certainly been wrapped in a very unhealthy secrecy.
Millions of UK citizens were involuntarily enrolled in a vast, long-running drug experiment, begun without any evidence that it might be effective, which they also unknowingly paid for out of taxes. And then when then the policy turned out to be a failure, patients still weren’t told about it, denying them the chance to make more informed decisions about how best to stay well. Meanwhile doctors are still handing out prescriptions and being paid for it.
Revelations of a whistle blower
The book is like a wonderfully readable release of data by a whistle-blower – revealing the internal workings of an industry that are normally shrouded in secrecy.
As his book says on the cover, we are all getting far too many pills and the reason is intimately connected with the way medicine is organised. In just fifteen years the number of prescriptions written by GPs has gone up three times, a rise which is implicated in the 75% increase in hospital admissions for adverse drug reactions between 1999 and 2008. The majority of these are elderly because they are more likely to be diagnosed as needing treatment.
The combination of drugs of limited effectiveness and a range of unpleasant, sometimes deadly, side effects being prescribed to everyone with biomarkers above a level that officially put them at raised risk for a chronic condition, has created a perfect storm for the elderly.
Devastating effects of a prescribing cascade
Between 1995 and 2010, the proportion of adults getting five or more drugs doubled to 20%. Le Fanu describes how this ‘prescribing cascade’ can happen. How in a matter of months a fit 70-year-old man put on a statin simply on the basis of his age, could be on six drugs.
This is of course exaggerated. Doctors are aware of it and even have conferences to discuss it. One practical solution is to develop a skill for which there are no payments – unprescribing, which my spellchecker tries to correct to ‘prescribing’.
And there is promising evidence for it. Ten years ago, a year-long study on 100 nursing home patients found that stopping 320 of their drugs cut the yearly mortality rate from 45% to 21% and dropped hospital admission from 30% to 11%.
But that’s not really an option for individual doctors. Not only does a huge weight of the evidence they rely on say these drugs are tested, effective and safe, but diagnosing a condition and prescribing a pill for it is what they do. Breaking ranks and ‘unprescribing’ could make them vulnerable to professional and financial penalties if a patient died or had a severe reaction. Prescribing these drugs may have modest to no benefits for patients; they are more reliably protective for the doctor.
This is an important, compassionate and carefully researched book that shines light on policies kept in the dark for too long. In a properly evidence-based system focused on patient needs it would prompt extensive discussions and a major re-evaluation. It certainly makes a powerful case for shifting to lifestyle medicine as fast as possible.
Read Jerome’s full piece here
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