What is the opportunity cost? This is a question I often ask our trainees. They are intelligent people, and make some educated guesses. But they are always wrong. The opportunity cost is a simple concept: if we did not spend the money on A, we could spend it on B instead. For example, the cost of a day in hospital is high, so would this money be better spent providing social care? The obvious answer is yes, but no one seems capable of making it happen.
NHS prescribing costs are chasing £20 billion, an opportunity cost of truly biblical proportions.1 But doctors are wedded to medications and we spend years drilling pharmacology into our heads at university. After that there is constant brainwashing from local drug reps and drug-sponsored education delivered by NHS consultants on the take. Consultants still get jetted to international conferences, sit on ‘advisory panels’, and are paid to educate the GP epsilons. All this makes doctors prescribing junkies.
But at what cost? The unravelling of much of US society thanks to the wanton overprescribing of opioids is now declared a national ‘emergency’.2 There is a constant rise of prescribing for mental health issues, despite limited evidence of benefit and plenty of evidence of harm around medicalisation and prescription dependence. Diabetic medication can cost £100 a month, but the opportunity cost would suggest that this money might be better spent on nutritional guidance, personal trainers, or alleviating poverty. The opportunity costs go on and on.
Polypharmacy is the new norm. Yet the greatest and most sustained state- sponsored polypharmacy terror of all time, the QOF, didn’t make any difference to mortality rates in the real world after a decade.3 This is odd as the impact should have been dramatic according to the ‘evidence’. Where are the professors who conceived this experiment now? And in case you hadn’t heard, the polypill doesn’t work either.4 Something has to give; there has to be correction to this prescribing madness.
So what to do? Nothing seem to be the preferred option. Medication is easy to start but seemingly impossible to stop. But there is a new kid in town: ‘deprescribing’, actively stopping medications! We must embrace this idea, because iatrogenic harm is the great public health challenge of our time.
Deprescribing should be a new movement, with T-shirts, placards, megaphones, a Twitter account, catchy slogans, and bands of angry, bearded young men and furious women with blue hair, seeking to tear down the medical institutions. But if not, then at least supply the resources to allow for pharmacists in general practice to review and actually stop medications — specifically NSAIDs, antihypertensives, painkillers, benzodiazepines, hypnotics, antidepressants, antipsychotics, and inhalers.
Lastly, isn’t it time we kicked Big Pharma out of the NHS, ban all contact, and break its pernicious influence in all things? Polypharmacy is the worst of all Bad Medicine and we must seize the deprescribing goal or it will be an opportunity lost.
- © British Journal of General Practice 2017