Some of the leading voices in UK health are calling for better support of healthcare professionals in tackling overprescribing that is crippling the NHS, saying GPs currently receive ‘lots of guidance on when and how to prescribe – but much less on deprescribing’.
At the conference, ‘Priorities for tackling overprescribing in the NHS’, which took place online via the Westminster Health Forum on October 18th, keynote speakers discussed issues including strategies for deprescribing, better equipping pharmacists and GPs to avoid future overprescribing and how patients can be empowered to question medication choices – particularly when it comes to opioids – made be practitioners.
Alongside the College of Medicine’s Chair Dr Michael Dixon, the first National Clinical Director for Prescribing for NHS England, Professor Tony Avery, and Katherine Le Bosquet, former Chief Pharmaceutical Officer’s Clinical Fellow for NHS England, addressed the online audience.
Critical psychiatrist Professor Joanna Moncrieff offered a powerful presentation on the use of antidepressants in the UK, saying one in six people are currently taking antidepressants ‘for months and years at a time’ despite little evidence that the benefits justify such long-term use.
The psychiatrist said the withdrawal process for patients from such drugs could be ‘difficult and distressing’ and they should be provided with more information before they’re prescribed them.
Nottingham GP Professor Tony Avery, who was made National Clinical Director for Prescribing for NHS England in March 2022, praised the ‘tremendous efforts’ by the NHS, bodies, industry, charities and patient groups to make improvements to remedy unnecessary prescribing.
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He told the audience that he hoped information sharing would be made easier; to prevent ‘time-wasting’ for GPs and pharmacists, saying: “One of the most important things happening in the prescribing landscape, a ‘game-changer’, is the Interoperable Medicines Plan”, which aims to consolidate a patient’s medical records.
He said that work over the last decade had seen ‘more records safely shared and accessed across care settings by patients and healthcare professionals.’
“To have an interoperable consolidated medication record means that we should no longer have admissions or pharmacists spending 40 mins trying to work out what medicines a person is taking when a patient is discharged from hospital.
“These records will save time, but also will help in reducing over-prescribing as well – including duplication. GPs and pharmacists shouldn’t spend ages trawling through records.”
Katherine Le Bosquet, who served as Chief Pharmaceutical Officer’s Clinical Fellow for NHS England in 2018/2019, said that the current biomedical model ‘favours medicine over alternatives’, and said patients often ‘struggle to be heard and are reluctant to challenge’ the medication prescribed to them.
Le Bosquet also called for more transparency of pharmaceutical sponsorship.
Our Chair, Dr Michael Dixon, laid out four ‘root causes’ of overprescribing in Primary Care including how medical schools train the next generation of doctors on prescribing, how funding flows affect prescribing and the fundamental ‘disconnection between doctor and patient and within our communities’.
He urged ‘over prescribing and over-medicalisation to be put into the forebrain of every doctor and patient’ saying ‘only if we do this can we emancipate both to do what is best rather than accepting the tyranny of commercial pressures and a medical model that has now had its time.’
READ DR MICHAEL DIXON’S SPEECH IN FULL:
Westminster Health Forum conference: Priorities for tackling overprescribing in the NHS, October 18th 2022
“Before discussing the root causes of overspending in primary care I want to congratulate Westminster Forum on holding this conference and Professor Tony Avery on his appointment and the excellent recommendations in the National Prescribing review.
Indeed, his role as the first NHS Clinical Director for Prescribing is symbolic of this now being a priority area for the NHS. I also want to mention my own College of Medicine’s Beyond Pills Campaign, which
you can see on our College website along with its six sets of recommendations.
We are in the process of enrolling Royal Colleges and associated health organisations in our cause with a very active campaign led by the College’s young doctors.
Moving more specifically to overprescribing in Primary Care, I believe there are four root causes – each with its own set of solutions – and inevitably I will be repeating or perhaps emphasising much of what we have already heard this morning.
The first is the medical and popular culture within which we all live. Let’s start with medical education. Our medical students spend numerous hours learning about drugs but almost none about relevant alternatives such as nutrition or social prescription.
Consequently, our campaign Beyond Pills Campaign has called for over prescription to now become part of mainstream medical teaching in the same way that we have been able to introduce social prescribing as a subject now taught in most good medical schools.
Things don’t get any better as medical students become doctors under duress to follow medical guidelines founded on population based evidence. Each guideline for a specific problem, more often than not, leads to a prescription but with an ageing population the polypharmacy that results may not be appropriate. NICE guidelines on cardiac risk, for instance, suggest that we should not tolerate more than a one in ten risk of a heart attack or stroke over the next ten years.
This leads to numerous men of my age being on several different drugs though many of us might think that a nine times out of ten chance of not getting a stroke or heart attack in the next ten years is a pretty good reason not to take anything!
For us GPs, the pressure of a ten minute consultation means that it is far easier to give a pill than to start trying to change a lifetime of unhealthy behaviour.
Indeed, giving a pill may be seen as an act of generosity although research does show that GPs think their patients expect pills more often than they actually do.
Patients themselves are also under strong pressures to seek a pill for every ill. Michael Balint has described our “Medicine addicted patients” looking for a quick fix.
One answer to the current burgeoning of prescription drugs and specialist referrals will be to provide those of us in primary care with the time and confidence to better use our own healing abilities and mobilise those of our patients.
The second reason for over prescribing is simply a perceived lack of satisfactory alternatives. A few years we GPs were criticised for not diagnosing depression often enough. Then when we did, we were criticised for giving out too many antidepressants though talking therapies had unacceptably long waits.
Today, thank goodness, we are beginning to see mental health practitioners working again in general practice and social prescribing is providing support and fundamental meaning to lives that have lost it. Ditto for musculoskeletal problems, where our patients have to wait many weeks before seeing a physiotherapist and few GPs now offer manipulation or other touch techniques out of fear of getting on the wrong side of the evidence base police.
The answer in future is to provide good and preferably direct access to services for mental health, physiotherapy, podiatry and other disciplines in general practice.
Pharmacists now working in general practice have a hugely important role in reducing the need to prescribe and may be it is time to reintroduce incentives to reduce prescribing.
Finally, there is that increasing team of now over 2,000 social prescribing link workers nationally who can provide useful alternatives using resources within the community.
The third reason why we over prescribe is a result of our health system and its funding flows. As you come into my surgery, ten flashing lights on my computer will tell me all the things that I need to do in order to get my quality points and thus money to keep my practice going. No one has ever paid me for sorting out the problem that you come to see me with and, worst still, no one has ever paid me to keep you healthy or measured whether I have been effective in doing so.
Politicians say they want a health service rather than a sickness service but how can this happen when all my payment and contract is about care rather than health? We all know about the ill effects of bad diet, inactivity, social isolation, polluted air, poor housing and lack of outdoor activity – to name a few – but these go well beyond are current contract.
In future, as well as funding more social prescribing link workers, we must start funding primary care and GPs to tackle the things that make us unwell – working alongside local authorities and the volunteer and voluntary sector.
Some GPs are showing that this is possible. A Stockport GP, Dr David Unwin, has shown that with time and determination you can cure Type 2 diabetes and has reversed this for a third of his patients reducing his prescribing bill by £68,000 per year. Why is no one paying me to cure diabetes but only paying me to record all sorts of details and to give tablets to keep sugar, blood pressure and cholesterol down?
Fourthly and finally, at the very root of our over prescribing is a fundamental disconnection between doctor and patient and within our communities. Tons of research has shown that if you see a doctor that you know and trust then you are less likely to get a prescription, less likely to be referred, will see health
professionals less frequently and are likely to be more satisfied with your care.
Against all this evidence, we have allowed that fundamental relationship between doctor and patient to be broken – so much that if you ask the average patient today who their doctor is they most probably don’t know. I have heard endless talk about how relationship continuity can be replaced by a relationship with a team or an organisation but I don’t buy it and neither, I think, do patients when they are very unwell, elderly or have long term disease – and these are the very ones that are the most vulnerable to polypharmacy.
Of course, providing relationship continuity is a challenge when so many doctors are now part time but their being part time is itself partly the result of our dysfunctional health system and it is possible to maintain continuity even with a part time workforce if there is the will. That disconnection between doctors and patients reflects a far wider disconnection within communities. It leads to isolation, depression and psychogenic pain.
I have described social prescribing as the “Trojan horse” for restoring health creating communities by widening the offer of local volunteer and voluntary activities. The next stage for social prescribing is for
the whole community to be engaged in signposting and developing non-medical options – such as Frome, Somerset, which has 1,800 community connectors – taxi drivers, hairdressers, shop assistants and students – protecting people from becoming ill and requiring drugs. In Ilfracombe, Devon, each street has a volunteer coordinator providing residents with volunteer/voluntary options, which may often substitute for pills.
In these straightened times, we urgently need to see a radical transformation of primary care from the purely biomedical to the more psychosocial. This needs to go alongside a fundamental move from population based care to personalised care. Discoveries around the biome and genome will mean, for instance, instead of giving tablets that are effective for 30% to everyone suffering from a given disease, we may in future prescribe only 30% of the tablets to those who will directly benefit.
More than anything, though, we must now put over prescribing and overmedicalisation into the forebrain of every doctor and patient. Because only if we do this can we emancipate both to do what is best rather than accepting the tyranny of commercial pressures and a medical model that has now had its time.”