NHS advises GPs not to prescribe “low value” drugs
BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j5599 (Published 30 November 2017) Cite this as: BMJ 2017;359:j5599
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Setting guidance on what not to prescribe would reduce NHS cost, especially the prescription dispensing fees.<1><2> But would it be easier to set up a national formulary on which drugs are covered or not? If a patient's clinical and social conditions warrant coverage for a non-formulary drug, then help the patient to apply for special authority access through the NHS. Now, it appears that the NHS wants the overstretched GPs to play judges, and determine which patient deserves a NHS prescription during their time-limited consultations.
It is difficult to imagine the arguments GPs need to encounter, to explain why some patients have paracetamol covered and some do not. That further recasts GPs’ role from “gatekeepers” to “barrier builders.”<3> Would GPs be legally covered if a patient suffered an ongoing illness due to failure to receive a NHS prescription?
Alternatively, why not purchase a package of paracetamol at cost, and have the salaried primary care pharmacists to dispense and counsel the patients in the GP clinics? This setup would save the NHS dispensing fees, and improve patients' understanding of medication therapies. Unfortunately, these pharmacists may be mainly used as an aid to reduce GP workload, rather than improving patients' quality of care.<4><5>
References
1. Iacobucci G. GPs call for end to “local rationing” of prescribing. BMJ. 2017;359:j5265.
2. Iacobucci G. NHS advises GPs not to prescribe “low value” drugs. BMJ. 2017;359:j5599.
3. McCartney M. Margaret McCartney: Are we reviewing GP referrals for the right reasons? BMJ. 2017;358:j4240.
4. Avery AJ. Pharmacists working in general practice: can they help tackle the current workload crisis? Br J Gen Pract. 2017;67(662):390-391.
5. Yeung EYH. Pharmacists are not physician assistants. Br J Gen Pract. 2017;67(665):548-548.
Competing interests: No competing interests
Let us hope that antidepressants are considered "low value" drugs, as well.
Recent evidence reveals that administered antidepressants actually increase suicide risks by 2-5 times. [2][3][4][5][6][9]
A recent meta-analysis, level I evidence, clearly demonstrated that SSRIs double the risk of suicide and violence in adults. [4]
Furthermore, antidepressants increase all cause mortality by 33%! [10][11]
Another meta-analysis published in the British Journal of Psychiatry has found that even patients with the most severe depression can expect to get as much benefit from cognitive behavioural therapy (CBT) as those with less severe symptoms. [7]
Even Behavioural Activation effectively decreases depressive symptoms. [8]
References
[1] http://www.bmj.com/content/355/bmj.i6761
[2] http://journals.sagepub.com/doi/pdf/10.1177/0141076816666805
[3] http://www.bmj.com/content/348/bmj.g3510
[4] http://www.bmj.com/content/352/bmj.i65
[5] http://nordic.cochrane.org/sites/nordic.cochrane.org/files/public/upload...
[6] http://www.bmj.com/content/355/bmj.i6103
[7] http://bjp.rcpsych.org/content/210/3/190.long
[8] http://www.bmj.com/content/356/bmj.j914
[9] http://www.bmj.com/content/358/bmj.j3697/rr-4
[10] http://dailynews.mcmaster.ca/article/antidepressants-associated-with-sig...
[11] https://www.ncbi.nlm.nih.gov/pubmed/28903117
Competing interests: No competing interests
Restrict prescriptions of “low value” drugs: The road to hell is paved with good intentions.
Redding, director of policy at National Voices, a coalition of 160 health and care charities, when commenting on the NHS England’s plan to limit the prescribing of “low value” drugs, claimed “This would risk adversely affecting those people who currently get free prescriptions, which includes some of the most vulnerable in our society.”(1)
First, Redding must understand that promoting autonomy and not giving faith to useless weird practices is the solution for the most vulnerable.
Second, the NHS is too shy. Why is acupuncture, relying on non-existent meridians, not on the list? (2)
Third, the list against “ineffective” practices will be ineffective because solutions must always consider roots. Why are grossly misleading advertising claims targeting the most vulnerable almost freely allowed?(3). Why does the system encourage fast-medicine while time for care is the cornerstone for providing explanations and reassurance to patients?
Last, the problem is far more serious than “low value” drugs. Is the list a smokescreen? Why are tens of drugs which should have been withdrawn from the market a long time ago still there? The French independent drug bulletin Prescrire publishes yearly a list of “drugs to avoid”: drugs with adverse effects that outweigh their benefits or drugs that have been superseded by others with a better harm-benefit balance.(4)
The NHS instead of explaining to healthcare professionals how they should do their difficult job should tackle the regulatory authorities (eg. Committee on Advertising Practice, Medicines and Healthcare products Regulatory Agency, National Institute for Clinical Excellence …) for not cleaning up the mess.
1 Iacobucci I. NHS advises GPs not to prescribe “low value” drugs. BMJ 2017;359:j5599.
2 Friends of Science in Medicine. Is there any place for acupuncture in 21st century medical practice? 29 July 2016. Available at http://www.scienceinmedicine.org.au/wp-content/uploads/2017/06/acupunctu...
3 Marron L. Complaint against British Acupuncture Council & 400+ acupuncture Websites. 22 December 2016. Available at www.scienceinmedicine.org.au/wp-content/uploads/2017/06/ukasaletter.pdf
4 Prescrire. Towards better patients: drugs to avoid in 2017. Prescrire Int 2017;26:108-1. Available at http://english.prescrire.org/Docu/DownloadDocu/PDFs/DrugsToAvoid_2017upd...
Competing interests: AB, as a French person, does not want to shame the NHS, as he is fully aware that France is the indisputable world leader for the production and prescription of homeopathic products. LM is the Chief Executive Officer of Friends of Science in Medicine.(http://www.scienceinmedicine.org.au/)