By Gavin Francis in THE TIMES, 19 May 2018:
One of my elderly patients, a delightful housebound woman called Agnes, has very high blood pressure, a condition that puts her at an increased risk of stroke and heart attack. For years I attempted to reduce Agnes’s stroke risk with medications, but after a week or so with each she would call me and say: “I just can’t take those pills, Dr Francis — they make me feel dreadful.” About five years ago I stopped trying. Now in her mid-nineties, she has yet to suffer a stroke or heart attack.
I stopped trying new pills because Agnes didn’t want them and had made an informed choice to take her chances — the effect of the pills is modest, and there’s no way of knowing if she would benefit. But every time I open her medical notes my computer flashes an alert telling me that I should be doing something about her blood pressure.
Alerts also flash up about her diabetes, her osteoporosis (fragile bones) and her cholesterol levels, which I also have to override — Agnes doesn’t want to ramp up her medications for these age-related conditions. She’s unusual: many people, when that told they could reduce the risks associated with ageing, agree to a prescription, although they may balk when they realise how tiny the benefit really is.
Since 2004 the money given to GPs to run their practices is directly linked to how closely they adhere to prescribing guidelines on blood pressure, cholesterol, diabetes, osteoporosis and dozens of other measurable outcomes, a system known as the quality and outcomes framework (QOF). NHS GPs are effectively self-employed rather than state employees, so close adherence to guidelines has the effect of increasing their income (although without any QOF income, they couldn’t afford to pay for their premises or their staff). Over 15 years the volume of medicines issued by the NHS has tripled. It’s estimated that 10 per cent of emergency hospital admissions are related to adverse medication reactions.
With Too Many Pills, James Le Fanu — GP, journalist, and Telegraph medical columnist — meticulously dissects the science, spin and unethical practices that have led the medical profession to this point. Take high blood pressure. Agnes is in a high-risk group, and there’s no doubt that reducing her blood pressure would mitigate her stroke risk. Yet the returns on treating mild high blood pressure are poor. With a mild increase in your blood pressure and no medication, your chance of not having a stroke over the course of one study was 97.4 per cent. Taking pills every day only improved those odds to 98.6 per cent; in a trial of 17,000 people just 50 benefited from the lifelong medication.
The number of people diagnosed with type 2 diabetes has quadrupled in 25 years, partly because of rising obesity and processed foods, but also because the goalposts for diagnosis have moved. Medical guidelines encourage an aggressive focus on blood sugar levels in the hope of reducing the long-term complications of diabetes (deteriorating eyesight, kidney problems, blocked arteries, nerve dysfunction). The QOF system has succeeded in driving down blood sugar levels nationwide, so we expect fewer of those complications.
However, there has been “no increase in life expectancy and quality of life from intensified diabetic therapy”, wrote John Yudkin of University College London; “tighter control conferred no benefit in reducing the incidence of coronary mortality, strokes, or total deaths”. It turns out that lowering your glucose levels doesn’t improve your survival, but does make you more likely to end up in hospital with a collapse from low blood sugar.
Too Many Pills builds on recent, excellent polemics concerning the relentless medicalisation of modern life, such as Margaret McCartney’s The Patient Paradox and Ben Goldacre’s Bad Pharma. As a medical columnist, Le Fanu has a voluminous mail bag; stories from it enrich his narrative, but also risk branding his conclusions anecdotal. When he sticks to the statistics his thesis is persuasive: doctors and patients have been hoodwinked by Big Pharma, and the QOF system of organising general practice causes harm. He quotes a recent government-sponsored review: “We have found no definitive evidence that QOF has had any significant effect on emergency admissions or population health or that it is an effective method for reducing inequalities in health and healthcare.”
So what’s to be done? Le Fanu is pessimistic as long as QOF remains in place. He doesn’t mention it, but in Scotland the system was quietly dropped last year, and a programme of “realistic medicine” is slowly bringing personal choice back into the consulting room, with a more balanced interpretation of statistics.
Britain’s rising climate of litigation doesn’t help — Too Many Pills opens with a disclaimer: “The information in this book is not intended to replace or conflict with the advice given to you by your GP or other health professionals . . . The author and publisher disclaim any liability directly or indirectly from the use of the material in this book by any person.”
To roll back the toxic effects of overdiagnosis and overtreatment, doctors and patients are going to have to have faith in one another. That means removing financial incentives from the consulting room and trusting people to make decisions about their own health. And in the meantime, with patients like Agnes, I’ll go on ignoring those alerts.
Gavin Francis is a GP in Edinburgh. His book on medicine and human change, Shapeshifters, is published by Profile/Wellcome
Too Many Pills: How too much medicine is endangering our health and what we can do about it by James Le Fanu, Little, Brown, 303pp; £13.99