When I started as a GP we had books for reference (often more than a few years out of date) and the library across town where, if we made a phone call, they would post us a paper on a requested topic, or reserve us a book. Now we have the world of knowledge at the click of a mouse and so have our patients. There is also the law of supply and demand to deal with in terms of the availability and supply of new drugs.
In discussing the vast increase in drug prescriptions over the last 10 years, I would like to give the example of statins, which is just one drug group that was not being prescribed when I qualified as a doctor, but is now taken by a large proportion of the population.
Statins were first marketed in 1987, the year after I qualified. It is widely thought that statins save lives and anyone who says otherwise probably belongs to the flat earth society or is mad. If I try to stop a statin now, some people are frightened they will drop dead from a heart attack tomorrow and it can be hard, if not impossible, to disabuse them of this idea, even if they are terminally ill with cancer. My patients in Padgate, Warrington were a delightful and not a particularly demanding bunch and even there 40% of our patients over 70yrs were on a statin. In my new practice, 60% of over 70s are on a cholesterol-lowering drug. That is just one drug group that has come into being since I qualified as a doctor, and there are many drug groups for other conditions like depression, indigestion, diabetes (incidence has gone up from 1% to 5% in last 23 years), asthma (now 12% of my practice population) all cleverly marketed by the Big Pharma companies, demanded by patients and more latterly promoted by the Department of Health through QOF.
QOF, the Quality and Outcomes Framework, is a very interesting phenomenon. Created by the government in 2004 along with the new contract, it set the scene for the systematic prescribing of drugs in a planned and measured fashion and on an industrial scale.
I can identify four key drivers: - Quality sounds good, performance pay sounds useful. - The government wanted an easy way of flexing GP pay on an annual basis. - Drug companies wanted GPs to systematically prescribe their drugs. - Key opinion leaders pushed for a systematic approach to managing their specialist disease areas.
All of a sudden a large proportion of core GP pay was replaced with pay related to QOF performance across many disease areas including hypertension, heart disease, asthma, COPD, depression and mental health and the systematic prescribing of key drugs became an integral part of the way forward for the next 11 years.
It is important to note that this performance related pay was labeled as being for providing high quality care. If a GP did not do QOF at all, he or she would be thought of as a poor quality GP and possibly unethical, but if a GP did do QOF s/he could be accused of doing it for the money even though s/he was just trying to provide a quality service. I do not know anyone who did not try to meet his or her QOF targets.
What are the disadvantages of QOF?
I can see five issues as follows: - There are fewer appointments for people who are ill. - There are side effects from drugs and reduced quality of life. - The cost to the NHS from the drugs themselves and treating any side effects. - The false belief that patients do not need to address their lifestyle e.g. in giving up smoking, or eating more healthily. - The need for other drugs to counter the side effects of the first drug and potentially others to counter the side effects of the second and so on. For an example, aspirin often leads to the prescription of omeprazole to protect the stomach. Steroid prescriptions often lead to the prescription of bone and stomach protection tablets.
How people were persuaded to take a statin:
Patients and doctors were persuaded by the relative risk figures, which implied that one was 30% less likely to die if on a statin (as the 4S study claimed).
However, when you realise that the best absolute benefit figures for extra life gained from taking a statin are 3 months extra life after 20 years in the highest risk groups, we were bowled over by the advertising. There are many upfront and hidden persuaders in the story of how drugs are pushed onto the market. The fact that this was all incentivised through QOF, made most people on both sides feel there was a lot of evidence behind it, and that it was sensible to comply. Few people questioned the simplicity and neatness of the 4 and 2 mantra, which came from one of the statin producing companies (that’s targets of 4 for total cholesterol and 2 for LDL for those wondering). The detailed information about lipid metabolism and statins takes very much longer to explain, and is well worth hearing.
What about NICE?
The National Institute for Care and Health Excellence (NICE) should be beyond reproach and in general it is thought that if NICE advise you to do something then, as a GP, it would be good to comply.
What I noticed as a GP was that there was a very public disagreement in 2013 and 2014, between various doctors at the top of the medical profession in and outside of NICE about statins and at what stage they should be used for cholesterol lowering. This disagreement called into question the impartiality of NICE. Around the same time, the Department of Health, without any fanfare, silently dropped virtually all of its QOF cholesterol targets for GPs for 2014/2015. Following this, I read widely about lipid metabolism and statins, and changed my practice in favour of open disclosure of risks and absolute benefits and informed patient choice. To do this I had to take more time over my consultations, but also make more savvy use of the Internet so that people went out of the room with a few web addresses or a book or article rather than a prescription.
How we get information about drug efficacy and side effects
We get information about drugs from the drug companies themselves (via representatives), from product literature and from the BNF (British National Formula) on line, which is readily available on our practice computer systems. We have less promotional material now, but I have the impression that we are also indirectly targeted via Key Opinion Leaders at meetings. The knowledge that negative trial data is not released has made me generally more skeptical about the claims about any product now and in the future.
What can be done about the overprescribing?
There are many ways in which ‘polypharmacy’ could be tackled quite quickly:
The Department of Health can continue to reduce the QOF element of GP remuneration.
GPs can direct patients to other ways of managing their problems rather than drugs, giving full information and promoting patient choice, and focus first on the vast variety of ways to treat a condition without a drug. I find most patients prefer non-drug choices where offered, especially in the areas of mental health and musculoskeletal problems.
GPs can become freelance doctors and be less tied to QOF.
Individuals can think for themselves, read widely, look at the information about the drug on the Internet, look critically at their own health and lifestyle and work out other ways to tackle their health issues.
Individuals should feel free to say that they are not interested in a drug and exercise their choice. People can opt out even if a course of treatment is recommended – this should be self evident – but people want to please GPs and do as they recommend. Stop it!
Honestly. Individuals, who aren’t taking a drug that has been prescribed to them, should tell their GP and ask him/her to take it off their drug list. I know someone who pretends to take a statin because they don’t want to hurt the GPs feelings and accepts the drug every month but does not take it.
Pharmacies can stop the automatic re-ordering prescription scheme as it leads to more wastage, through people’s drugs changing in between prescriptions.
GPs and pharmacists can review and stop unnecessary drugs in older people, because they are more prone to side effects. Some tests have shown that older people whose drugs are rationalised and reduced have better outcomes and live longer. For instance, we may have forgotten that in the case of statins, even the manufacturers advise caution over the age of 70, so this needs to be discussed and reviewed.
When I was doing my prescriptions on Friday, I was struck by the prompts on the screen: medication review due; blood pressure due; CHADS2 score needed (for stroke risk) – all of which might lead to more or less prescribing. I was also struck by the large numbers of drugs some older people were taking, for which there is no good rationale, as the drugs are only tested individually and not collectively.
I am going to finish with some real examples of “not strictly necessary” prescribing that would not have happened at all, or as much, in 1990, and which I came across on Friday in the course of my work: - Iron tablets, which many people (either short of or not short of iron) might have bought for themselves. - Diprobase emollient (eczema cream), which would previously have been bought over the counter. - Terbinafine for fungal nail infection. This did not exist until 1991. - Memantine for memory problems, which was not used much until recently, although it has been around since 1968. - Aspirin, which often causes side effects for which lansoprazole is prescribed. Lansoprazole did not exist in 1990, and aspirin was not prescribed systematically as it is now. - Triptans for migraine, which was not marketed until later in the 90s.
A patient of 85 years of age took the following list of drugs, about half of which were not around in 1990. I have highlighted the ones for conditions that could be treated in a non-drug fashion as well as adding in comments about the other choices. - Citalopram for depression - Folic acid (a B vitamin) - Fultium (vitamin D) - Alendronic acid for osteoporosis - Ferrous sulphate iron tablets - Irbesartan for high blood pressure - Methotrexate for arthritis - Naproxen for arthritis- would have been safer to take paracetamol - Omeprazole as a stomach protector to cover the side effects of the citalopram and the naproxen- not necessary if citalopram and naproxen are stopped - Simvastatin for cholesterol. The patient leaflet cautions against use in over 70s, so could be stopped - Sotalol to control the heartbeat - Mometasone spray for allergic rhinitis
The 77-year-old patient whose medication is pictured below took her medication 3-4 days a week, and never took her statin (photo with permission). Note the two boxes of lansoprazole of different brands, which might confuse and the two sorts of GTN spray. There is no evidence that taking them 3-4 days a week is helpful, so she would be as well off taking none at all.
So, last week’s news that prescriptions are up by over 50% in the past decade, sadly doesn’t surprise me at all. Mass medication has become institutionalised – embedded in GP frameworks as far as our pay packets. NICE conflicts add to the problem and drug company profits are too eye watering to think change will come from their quarter, but they are patients too, and I am not without hope. For my part, I consider it my duty to put my patients and ethics first, and first do no harm and then hopefully a lot of good.