Prescribing: Restricting access to 'low value' treatments is a false economy

NHS England's decisions on treatment effectiveness appear to be based on a very narrow interpretation of what is evidence-based medicine - which means cheaper medicines may be replaced by costly alternatives that patients often find less effective, argues Dr Gabriella Day.

Dr Gabriella Day
Dr Gabriella Day

NHS England’s recent decision requiring GPs stop prescribing a list of 18 medicines will reinforce the fears of many doctors that healthcare rationing is being introduced by the back door. I would also argue that it is an illogical and ill-informed decision that will not achieve the professed aim of saving NHS resources.

The decision to impose a blanket ban on these items will disproportionately affect those patients who currently receive free prescriptions: the young, the poor and the elderly. The conditions these patients are suffering from will persist. 

If in future these vulnerable patients want to continue with their medicines, they will be forced to pay for them. While wealthier patients will have the option to pay for their medications, those unable to do so will return to their GP for an alternative medication or procedure that has not been prohibited by NHS England’s recommendations. GPs will then find themselves prescribing other more costly medications. How this is helping NHS England to reduce prescribing costs is difficult to see.

With the health service is struggling under severe financial pressure, it is right that NHS England offers guidance on the commissioning of treatments. But its decisions on treatment effectiveness appear to be based on a very narrow interpretation of what is evidence-based medicine (EBM).

This slavish adherence to this form of EBM is creating the false economy where cheaper medicines are being jettisoned for costly alternatives that patients quite often find less effective, or cause adverse reactions that require more prescription drugs.  So more money is spent – not less – exacerbating the funding crisis that inevitably leads to more healthcare rationing.

Evidence-based medicine

The concept of evidence-based medicine was originally designed to ensure that patients received the best care as demonstrated by the available research. The term originally covered the results from several areas of research: clinical trials, patient outcome studies and individual clinical experience.

In recent years, however, the former has been hailed as the pre-eminent test for the evaluation of treatment efficacy. Far from instilling greater confidence in doctors for the medicines they are prescribing, a survey conducted by the Academy of Medical Sciences in London found 82% of GPs believe drug trials conducted by the pharmaceutical industry are skewed towards a positive conclusion.1

Even from inside the pharmaceutical industry, the efficacy of the drugs it manufactures has been questioned. In 2003, a senior executive at GlaxoSmithKline admitted that most drugs are ineffective for the majority of patients they’re prescribed for because genetics interfere in some way. Dr Allen Roses, then GSK’s worldwide vice-president of genetics, said: ‘The vast majority of drugs – more than 90% – only work in 30 to 50% of the people.’

Part of the problem is that complex patients – those suffering from more than one condition, the elderly and vulnerable – rarely feature in clinical trials, even though they make up the largest part of the NHS’s workload. Research funding for clinical trials is disproportionately allocated to younger people with single diseases. 

So perhaps we shouldn’t be surprised that despite the health service adopting EBM as the principal criteria on which treatment funding decisions are made, there has been no corresponding improvement in patient health. This raises the question of whether we are evaluating treatment efficacy correctly.

Evidence-informed practice

It is widely recognised that most patients do not fit into the rigidly controlled clinical scenarios on which EBM is based. Instead, doctors use ‘evidence-informed practice’, which involves using any available evidence, then evaluating and adapting it to inform their practice, not dictate it.

This not only includes scientific research, but also evidence from clinical practice acquired over many years and endorsed by numerous clinicians. Yet this type of evidence, from the front line of medicine, is being dismissed as ‘unscientific’ or ‘anecdotal’.

This has led to the present situation where an over reliance on the results of clinical trials is seeing expensive new drugs adopted that have limited clinical effect. At the same time there has been a rush to decommission an ever growing list of medicines and treatments, even though doctors prescribing these treatments – and the patients receiving them – are reporting improvements in health.

We all want the NHS to operate cost effectively, but to simply ban treatments that fail to meet current EBM criteria is short sighted. Of course, treatments that have no good evidence of benefit to patients should be questioned. However we need to use some common sense in how we evaluate these. And the key questions we should be asking are:

  • Do patients find it improves their health and quality of life?
  • Is the treatment expensive?
  • What is the cost of the alternative?

If these questions are not addressed when reviewing treatments, we have to wonder what the aim is in conducting the review in the first place.

NHS England needs to conduct a review of how it evaluates treatments and take far more notice of the experiences of doctors and patients. Then perhaps we will see a more financially efficient health service, healthier patients and an end to the injustice of healthcare rationing.

  • Dr Gabriella Day is a GP in Southampton

Reference
1. Academy of Medical Sciences: Medical Information Survey. April 2016.

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