Too Much Medicine?

 

Back in 1990 I wrote a paper for this magazine entitled Surely there is something in it: The social psychology of healing in which I said the following: “I insist that if you put together mainstream public and private medicine, alternative or complementary medicine, commercially available, across-the-counter remedies, and so on, then you have a healing industry the collective scale of which vastly outstrips whatever it is really capable of achieving. In short, there seems to me to be far too much of it about. And yet the constant message that I am hearing is that we need more of it”.

Despite the great advances in medical science since then, nothing that has happened has made me alter this view. Just in the month prior to penning this I noticed three news announcements that only serve to support my impression that things have not changed. Firstly, Professor Andrew Carr, an orthopaedic surgeon at Oxford University Hospitals, was widely reported as claiming that “Thousands of people could be undergoing unnecessary, risky and expensive surgeries as most procedures have never been subjected to the rigorous testing drugs are required to have”. He added that the benefits could be partly or entirely explained by patients’ strong expectation that their symptoms would improve after treatment.

Hot on the heels of this came the admission by NHS England that millions of people are needlessly sent to hospitals and GP surgeries by the NHS 111 helpline; eighty per cent of referrals to GPs and A&E could be avoided if callers were able to speak to a doctor.

At the same time, it was reported that the prescription of antidepressants in England doubled over the last decade, despite the expansion of non-pharmacological treatment (‘talking therapy’) under the Improving Access to Psychological Therapies programme which is now used by over 900,000 people per year. I should also mention the ongoing scandal of the over-prescription and misuse of painkillers and antibiotics.

In addition to the above, this July NHS England’s Clinical Commissioners published a report with the title Items which should not routinely be prescribed in primary care: A Consultation on guidance for CCGs. This report listed a range of treatments currently prescribed within the NHS without sufficient justification. To the delight of skeptics these included homeopathy and herbal remedies, which the report considered to be of no proven efficacy. But the sums of money currently spent on these are minute compared with the other treatments on the list.

The issue of unnecessary medicine (in all its aspects – investigation, diagnosis, treatment, etc.) – has now become a personal matter for me following a recent call from my GP. Some years ago I had a cholesterol test which was low ‘borderline’ and I was advised that no intervention was necessary. Now my doctor informs me that the NHS guidelines have been modified and the cholesterol reading I had previously now puts me in the range of someone who would be advised to take statins indefinitely.

For me, the possibility that any treatment that I am offered is unnecessary is a risk factor, even if the treatment itself has no lasting adverse consequences. I have seen too many patients in my professional work – not to mention friends and family members (pets included) – undergoing interminable treatments and consuming enormous quantities of pills every day, without any clear indication as to what, if any of it, is of real benefit to them. If nothing else, there are better ways of spending NHS money.

Coincidentally, a relevant and very informative article by Dr Harriet Hall appeared in July on the Science-Based Medicine website entitled Most patients get no benefit from most drugs. The article is mainly about the dilemma of whether or not to take statins and discusses the importance and limitations of the number-needed-to-treat (NNT) statistic – that is the average number of people that it is required to treat before one of them will benefit. As expected the NNT for statins depends on the population the ‘number of people’ are drawn from (i.e. their risk profile – age, prior medical history, current health status, etc.) and how ‘benefit’ is being assessed (e.g. prevention of heart attack). The risk of adverse side-effects (severity and number needed to harm) is something else to take into consideration – in Dr Hall’s opinion these have often been overstated in the case of statins.

Dr Hall refers the reader to the NNT website where one may look up the NNTs of treatments for a various illnesses and conditions, and a website constructed by the Mayo Clinic to assist physicians and patients who are considering statin medication. Incidentally, some of the treatments listed on the NNT website are of no benefit at all and Dr Hall mentions some of these. However she cautions about being unduly alarmed by high NNTs for quite common treatments such as statins; it’s a blunt instrument for informing clinical decisions.

That over-screening, over-testing, over-diagnosis and over- (not to mention ineffective) treatment are a problem that is acknowledged by professionals within the orthodox medical establishment is a testament to their honesty and integrity (can one imagine purveyors of alternative medicine issuing similar warnings about their practices?). In fact several years ago the British Medical Journal launched an initiative with the uncompromising title Too Much Medicine, whose annual conference was held in Oxford this April. The BMJ is also represented at this year’s Preventing Overdiagnosis conference in August in Quebec (mission statement – “winding back the harms of too much medicine”.

So back to my dilemma. As to whether I’ll decide to take statins or not, I’ll let everyone know later this year – if I’m still around.

 

Michael Heap is the chairman of ASKE and is a clinical and forensic psychologist in Sheffield.