The irony is that the healthier Western society becomes, the more medicine it craves … Immense pressures are created – by the medical profession, by the media, by the high pressure advertising of pharmaceutical companies to expand the diagnosis of treatable illnesses. Scares are created, people are bamboozled into lab tests, often of dubious reliability. Thanks to diagnostic creep or leap, ever more disorders are revealed, extensive and expensive treatments are then urged … [This] is endemic to a system in which an expanding medical establishment, faced with a healthier population, is driven to medicalising normal events, converting risks into diseases and treating trivial complaints with fancy procedures … The law of diminishing returns necessarily applies. Extending life becomes feasible, but it may be a life exposed to degrading neglect as resources grow overstretched. What an ignominious destiny if the future of medicine turns into bestowing meagre increments of unenjoyed life?*
The burden of chronic diseases, also called ‘non-communicable diseases’ or NCD, is increasing nationally and globally because of changing demographics – populations are increasing in number, people are living longer and more people are becoming obese. The biggest cost of the NHS (indeed of healthcare in any developed country) is looking after people with chronic diseases such as high blood pressure (hypertension), vascular diseases like heart disease and strokes, lung diseases like asthma and COPD, endocrine diseases like diabetes and so on. Many previously acute illnesses like HIV and cancer have now reached the stage where treatments have advanced sufficiently that people can survive for many years with often expensive treatment and so they too are defined as chronic diseases or NCDs. Globally, NCDs account for more than 60% of deaths and the proportion is expected to rise significantly.
The shifting sands of governmental justification for NHS reforms have moved on. After critics pointed out that their claims about heart disease and cancer outcomes lacked any evidence, they have now started talking about the undeniable rising costs of modern medicine and an aging population. They propose a one-size fits all approach to solving the problems: open the NHS up to competition and rely on the innovation and dynamism of the market to come up with solutions.
But the increased costs of preventing and treating NCD are not only a consequence of demographics and technology, they are also due to:
- Increased identification of NCD due to public awareness and screening programmes
- Increased treatment for those already affected (many are identified but undertreated)
- Reduced thresholds for diagnosis
- New diseases and disease definitions
- New treatments including drugs and procedures
- Reduced thresholds for treatment
- Perverse incentives: the medical industrial complex
- Increasingly sedentary work and leisure activities
- Increasing consumption of high sugar/ fat/ salt processed foods
- Increasing inequality
It should be immediately clear the plans for the NHS will do very little to reduce the cost of NCDs. The general scope of the reforms – greater commercialisation and a lack of action on social determinants of health – will further the wholesale medicalisation of populations by situating preventative interventions at the level of the individual rather than at a societal or global level. Consequently healthcare in the UK (and anywhere else for that matter) will be unsustainable.
The hidden NCDs.
Huge numbers of people have NCDs but have not been diagnosed, for example up to half a million people in the UK are thought to have diabetes without knowing it. There are plans to increase screening programmes to identify people with undiagnosed high blood pressure and high cholesterol, as well as different cancers. If successful they will increase the incidence of NCD far beyond demographic effects.These plans are not without controversy, especially for conditions with an uncertain prognosis when the impact of a diagnosis and subsequent treatment may be worse than doing nothing, like prostate cancer or certain types of breast cancer, but the trend is for more screening, not less. Commercial medicine is particularly sinister in this respect offering ‘full body MRI scans’ and other screening tests with no proven benefits and high risks of false positive findings which lead to further investigations and treatment.
The not yet NCDs.
Treatment involves not only managing the effects of the disease, but also in preventing their development by treating risk-factors such as high cholesterol and obesity. Even very small reductions in thresholds for treatment, at a population level capture enormous numbers of people for whom medication is indicated. In 2003 the European guidelines changed thresholds for treatment of hypertension and high cholesterol to a level that would include 90% of people over the age of 50 with little or no benefit. A study published this month went further suggesting that everyone over the age of 55 should take medication to lower their cholesterol.
New diagnostic thresholds amount in some cases to new diseases, such as ‘pre-hypertension’ and ‘pre-diabetes’. A 2010 revision of the diagnosis of ‘gestational diabetes’ lowered the threshold for diagnosis so far that it would include 20% of all pregnant women.
The new NCDs.
The case for psychiatry is excellently summarised by Mikkel Borch-Jacobsen in ‘Which came first, the condition or the drug?’
In the case of bipolar disorder, this conceptual gerrymandering has involved stretching and diluting the definition of what used to be called manic-depressive illness so that it might include depression and other mood disorders, thus creating a market for antipsychotic or anticonvulsant medications that were initially approved only for the treatment of manic states.
One of my patients described visiting his psychiatrist who doodled on his Seroquel branded note with his Seroquel pen, before prescribing … Seroquel. My personal memory of working as a hospital psychiatrist was that it was the most ‘branded’ of the 6 hospital specialities I worked in.
Disease mongering is the “selling of sickness” in order to promote drug sales, but it is only the more extreme end of a general tendency to reduce thresholds and expand diagnostic boundaries. The campaigning journalist, Ray Moynihan in the latest issue of British Medical Journal covers a lot of these issues.
On a more positive note, but one that will nevertheless increase the burden, is that improvements in treatment will increase the time that people can expect to live with a wide range of cancers and other chronic diseases. It will, however be very expensive.
The burden of medication.
The numbers of prescriptions issued are rising dramatically with the highest increase in drugs relating to the cardiovascular system. The elderly received the greatest increase in numbers of drugs issued: on average people over 60 received more than 42 prescription items per head in 2007 compared to an average only just over 22 in 1997. Hospital admissions for adverse drug reactions (ADR) are increasing substantially and particularly so in the elderly. Between 1999 and 2008 the annual number of ADRs increased by 76.8%, and in-hospital mortality rate increased by 10%. In 2008, there were 75,076 drug-related emergency hospital admissions. There has been a near 2-fold increase in kidney and cardiovascular consequences due to prescribed medications.The number of medications a patient takes is associated with the risk of an adverse drug reaction, with the mean rate increasing by 10% with each extra medication prescribed.
Quoted in the Telegraph today, Cameron says that the cost of medications for the NHS is rising by £600m a year, but he makes no indication of how this might be reigned in. In the UK GPs prescribe a higher proportion (over 80%) of generic drugs than in any other EU country, making significant savings over branded drugs, so there is not much room for savings here. For cancer drugs costs will increase significantly now the government has created a £200m cancer drug fund to pay for more drugs. As health journalist Andy Cowper points out,
the ridiculous National Cancer Drugs Fund offers the perfect example of how to waste over half a billion pounds over three years. It is even more ridiculous when considered in tandem with the Coalition pitch to move to value-based pricing of pharmaceuticals, when the only NHS scheme to attempt this at scale was evaluated by the BMJ as “a costly failure”.
The typical patient.
John, is a ‘typical’ patient with diabetes. He is 55 years old. For his diabetes he is prescribed 3 drugs. He also has hypertension and is prescribed another 3 drugs. He has high cholesterol and is prescribed a statin. He is depressed and is prescribed an anti-depressant, and for his chronic back pain takes 2 different analgesics 4 times a day. He has neuropathic pain in his feet and takes another drug 3 times a day, which also helps with his back pain. He takes one aspirin a day and a vitamin D supplement. He is allowed 4 Viagra a month for his impotence.
Because many of the medications have to be taken more than once a day, and he has to take more than one tablet to make up the correct dose, in total he ‘should be’ taking 28 tablets daily, with occasional additional use of viagra.
Many of my ‘typical’ patients with diabetes also have heart disease and/or lung disease each with their regime of medications to be added on. If John were to have a heart attack it is quite likely he would leave hospital with an additional three or 4 prescriptions.
I was careful to say that ‘John was prescribed’, rather than ‘John takes’ these medications. Estimates vary but roughly only 1 in 6 patients take medications exactly as prescribed and 20% of prescriptions are never cashed in the UK. There are a huge amount of wasted prescriptions, up to £300million a year. Reasons include side-effects, inconvenience, poor understanding, forgetfulness and so on. When patients with chronic diseases like John are prescribed such intimidating numbers of tablets it is no surprise that they simply do not bother to take some of them. We doctors need to ensure that our patients are only prescribed the medications that are going to be effective and that they are willing and able to take effectively. This is tremendously complicated and there is no simple solution, certainly none that will create the short-term savings the government are forcing on the NHS. For us (doctors) to add a set of new medications with every new disease is not in the interests of our patient or the NHS, but it is what we are presently doing, in part becasue we are paid to ensure we prescribe a recommended bundle of medications for each condition.We urgently need real world research to help rationalise prescribing in patients with multiple co-morbidities. Unfortunately NICE, which is best placed to make cost-effective recommendations is being cut by this government just when it is needed more than ever.
All of the points I have described will increase the financial burden of chronic diseases. There is nothing in the reforms to do anything about them. The NHS needs to increase funding by 6-8% a year to keep up with changing demographics, but funding has been frozen. Consequently,
Patients will have to start paying for their care.
What are the alternatives?
As recommended by the World Health Organisation and highlighted in the BMJ this week, the most cost-effective way to prevent many NCDs is to act ‘upstream’ on the social determinants of health rather than downstream at the level of individuals. This will involve serious and concerted efforts to tackle the effects of food markets globally, and the food and alcohol industry nationally. Sadly our government have shown no interest at all, instead opting for meaningless partnerships with industry and emphaising individual responsibility.
Another potential solution is to involve the public in a debate about how limited resources should be distributed. Satisfaction with the NHS is at an all time high even amongst Tory voters and is mirrored by enormous levels of opposition to the reforms. We are used to a health service that distributes care according to need. Indeed that is the point of the NHS. The British public are small c conservatives and suspicious of change, but we also pride ourselves on our sense of justice. Serious involvement of the public, rather than industry sponsored single interest groups, might help draw the line at medical interventions, especially intensive and degrading end-of life treatments, and increase the demand for social action. (I say ‘might’ because there is evidence that patients with cancer opt for more intensive chemotherapy than doctors.) Nevertheless patients are clearly not taking the vast amounts of drugs we are prescribing.
It is possible that infectious diseases will play a huge role in expanding costs as well. The massive industrial scale of food production, the rise in use of antibiotics and antivirals in animal feeds combined with the ability to mass-produce vaccines can lead to sudden, unpredictable and unprecidented healthcare costs.
NICE needs increased support and a greater remit to provide doctors and patients with clear advice about cost and clinical effectiveness about treatments in complex chronic conditions and co-morbidities.
At a time when the government are forcing on the NHS the deepest and most sustained cuts it has ever experienced while the burden of chronic diseases is set to explode, we need to take control of our NHS.
*Roy Porter, The Greatest Benefit to Mankind: A Medical History of Humanity. Quoted in Le Fanu, The Rise and Fall of Modern Medicine. (this link is to a review in the New York Review of Books by Richard Horton. It reveals some of the flaws and prejudices in Le Fanu’s book)
Over the last half century, life expectancy in the industrialised world has risen dramatically – and so has the healthcare bill. Is population ageing the main reason? This column argues that while ageing does affect health spending, it is far less important than many think. It adds that obsession with an ageing population is a dangerous red herring that prevents dealing with the real culprits of rising costs.
I had an exchange on Twitter in response to the article above with Professor John Appleby (Chief Economist at the King’s fund) and another NHS chief economist Dr David Parkin. They confirmed that ageing makes a very small difference to overall costs, as little as 1% real terms growth PA. The 2002 Wanless report and an EU report that confirm this. Prof Appleby questioned whether the NHS was really unaffordable in the BMJ 13.7.2011 and the government repeated their assertion that costs were rising because of the ageing population.
A presentation by Wouter Bos, ex-Norweigan finance minister and now partner Performance & Technology Public Sector at KPMG, asks the question, “Is technology the answer to rising costs in healthcare?” The answer … “No”.
“The most important reasons for the uniquely high costs of the US health system are its commercialization and the effects of business incentives on the provision of care. The US has the only health system in the developed world that is so much owned by investors and in which medical care has become a commodity in trade rather than a right.”
Health Care: The Disquieting Truth Arnold Relman New York Review of Books
Update 24.01.2012 Rethinking NCD Chatham House 24.01.2012 Although the most effective interventions on tobacco, food and alcohol contain fiscal and regulatory threats for individual industries, these merit consideration given the positive economic effects for businesses in general
The reasons for increasing costs urgently need addressing, but they’re not to be found in this healthbill.