The Polypharmacy Challenge Blog
Book Review: Too Many Pills by James Le Fanu
“In just fifteen years the number of prescriptions issued by family doctors in Britain has increased three-fold. Everyone agrees this is too many…”
This is the opening sentence of James Le Fanu’s thought-provoking book: Too Many Pills - How Too Much Medicine is Endangering Our Health and What We Can Do About It. It begs the question that if everyone agrees, then how has this come about? And what is sustaining this situation? These are questions that are of interest to us in the APOLLO-MM project so I was keen to learn what Le Fanu has to say on the matter.
Le Fanu is a General Practitioner and a columnist for The Telegraph. In this book, he draws on a range of sources – the academic literature, his own experience as a GP, and letters he has received from his column readers – and brings these together to present a readable and compelling, if somewhat disturbing, argument. He makes his own stance on polypharmacy abundantly clear; it is, he says, undesirable ‘folly’ and the cause of much unnecessary misery. He identifies a range of system level and institutional factors that lie behind it, but insists that the solution lies with the general public. To this end, the book is a ‘call to arms’ in which he invites readers to seize control of the situation by engaging their doctors in some frank conversations that are not often happening.
Le Fanu traces the origins of the ‘too many pills’ situation to two key notions, which together serve to propel polypharmacy.
First, the ambition of drug companies to expand their markets beyond the ‘ill’ to ‘sell to everyone’ (primarily by harnessing the notion of ‘risk of disease’ where the possibilities are seemingly endless). And second – originating within academic circles – the ‘population approach’ to treatment, in which the focus of medical activity becomes reducing average levels of certain attributes (e.g. blood pressure, cholesterol) across the population, rather than concentrating efforts on those people in whom these measurements are very elevated.
This shift in focus has two consequences. It exposes many more people to medicines than would have received them before, and it changes the balance of benefits and harms. The benefits of a medicine (at the level of the individual) for someone who is at very low risk of a particular unwanted outcome may be more marginal, but the risks of exposure to the medicine by way of side effects are the same. Where one ‘draws the line’ is, of course, a complex matter for judgement (a topic that Le Fanu does not engage with to any great extent) but there is no mistaking that he believes lines are being drawn in the ‘wrong’ places.
Le Fanu blames the 2004 changes in contractual arrangements for general practice (principally the introduction of QOF in which GPs are rewarded for treating a wide range of conditions to measurable targets) as the institutional glue which enables these two key drivers to combine to create the current situation. He argues, quite forcibly, that doctors (does he include himself I wonder?) do not do enough to ensure truly informed consent when prescribing medicines, which would include a more candid explanation of the limits of medicines as well as their (sometimes marginal) benefits. Indeed he charges GPs with being ‘deeply complicit’ in a ‘hidden epidemic of iatrogenic illness’; illness caused by medical examination or treatment. He concedes this is quite ‘unintentional’ since it is actively encouraged by a range of widely endorsed guidelines informing ‘good’ clinical practice (the implementation of which provides general practices with a substantial proportion of their income these days).
Le Fanu focuses in some detail on particular examples from practice, illustrated with stories gathered from his column readers’ letters. For example, there is a chapter entitled All Must Take Statins in which he explains how certain ways of presenting ‘risk’ statistics (e.g. ‘relative risk’) can hide much more modest ‘absolute’ benefits for particular patients. He suggests that if patients only knew how modest the benefits often are, then they might not always be so keen to take them. There are a number of persuasive patient testimonies to illustrate the various ills that can result.
Another chapter, provocatively entitled Good Doctors and Bad Medicine, introduces readers to some of the details of the QOF and presents a fairly damning account of its ‘profound effects on traditional family doctoring’, describing it as a bold (but ultimately unsuccessful) experiment in the ‘population approach’ and a means by which government has been able to directly control what GPs do whilst making patients of everybody through ‘profligate over-prescribing’.
Too many pills is a thought-provoking read. It deals with some complex concepts (such as Number Needed to Treat) and tricky epidemiological issues as simply as I suspect is possible. The inclusion of patients’ testimonies is effective, though arguably unlikely to represent the range of views people hold about their medicines. It is, without doubt, the voice of a fierce critic of polypharmacy, as the title makes plain. And one of his key messages is that change is only ever likely if it is demanded by the general public - so entrenched has polypharmacy become in current medical practice.