Category Archives: pharmacists

The evidence basis of all practice(s) needs to be challenged – continuously. There are perverse Incentives in private systems, but why do the UK health services still overtreat?

David Epstein in propublica (Atlantic) on 22nd Feb 2017 writes/asks: When Evidence Says No, but Doctors Say Yes = Long after research contradicts common medical practices, patients continue to demand them and physicians continue to deliver. The result is an epidemic of unnecessary and unhelpful treatments. (Such as Bisphosphonates)

Image result for bad pharma cartoon

You can listen to the article  HERE, and the importance of evidence based medicine, study replication and critique becomes vital. In the UK we see the over prescribing of anti-depressants to elderly people (BMJ 2011;343:d4551 ) when over 90% don’t work and 7% cause side effects (At present unpublished data). In orthopaedics we were given the solution to cross infections and waiting lists in 1983, but have moved in the opposite direction, closing cold orthopaedic hospitals or denying them as choice options to patients. In addition, clips closing skin wounds have been shown to increase infections by 300% but are still used because they are faster! The article covers heart disease, hypertension, knee injuries and other conditions that need systematic evidence review. What has never been measured is morbidity and mortality for patients who wait longer for operations (Hips and Knees especially) as there is no public database, and big pharma are not concerned. Indeed, waiting lists mean more drugs, prescriptions and side effects. Proposed legislation to reduce efficacy thresholds (USA) could increase the influence of “pharma” when the opposite is needed…

For a summary read from this link. When Evidence Says No, But Doctors Say Yes

Summarising:

Stents for stable patients prevent zero heart attacks and extend the lives of patients a grand total of not at all.

Atenolol did not reduce heart attacks or deaths—patients on atenolol just had better blood-pressure numbers when they died.

The consultants approach: “Just do the surgery. None of us are going to be upset with you for doing the surgery. Your bank account’s not going to be upset with you for doing the surgery.”

When looking at cross-over trials for cancer: “If the treatment were Pixy Stix, you’d have a similar effect. One group gets Pixy Stix, and when their cancer progresses, they get a real treatment.”

When distinguishing between relative and absolute risk: “Relative risk is just another way of lying.”

The article ends:

In 2014, two researchers at Brigham Young University surveyed Americans and found that typical adults attributed about 80 percent of the increase in life expectancy since the mid-1800s to modern medicine. “The public grossly overestimates how much of our increased life expectancy should be attributed to medical care,” they wrote, “and is largely unaware of the critical role played by public health and improved social conditions determinants.” This perception, they continued, might hinder funding for public health, and it “may also contribute to overfunding the medical sector of the economy and impede efforts to contain health care costs.”

It is a loaded claim. But consider the $6.3 billion 21st Century Cures Act, which recently passed Congress to widespread acclaim. Who can argue with a law created in part to bolster cancer research? Among others, the heads of the American Academy of Family Physicians and the American Public Health Association. They argue against the new law because it will take $3.5 billion away from public-health efforts in order to fund research on new medical technology and drugs, including former Vice President Joe Biden’s “cancer moonshot.” The new law takes money from programs—like vaccination and smoking-cessation efforts—that are known to prevent disease and moves it to work that might, eventually, treat disease. The bill will also allow the FDA to approve new uses for drugs based on observational studies or even “summary-level reviews” of data submitted by pharmaceutical companies. Prasad has been a particularly trenchant and public critic, tweeting that “the only people who don’t like the bill are people who study drug approval, safety, and who aren’t paid by Pharma.”

Perhaps that’s social-media hyperbole. Medical research is, by nature, an incremental quest for knowledge; initially exploring avenues that quickly become dead ends are a feature, not a bug, in the process. Hopefully the new law will in fact help speed into existence cures that are effective and long-lived. But one lesson of modern medicine should by now be clear: Ineffective cures can be long-lived, too.

NHS rationing: hip-replacement patients needlessly suffering in pain on operation waiting lists

The physiotherapists research: Toby Smith & Debbie Sexton, and two consultants (Donell and Mann) in 2010:  Sutures versus staples for skin closure in orthopaedic surgery: meta-analysis (BMJ 2010;340:c1199 ) – found a 3 fold or 300% increase in infections

Blunders. Iatrogenesis continues to be very important – for us all. It may become more so…

The nation hooked on prescription medicines – no more than many others actually..

 

 

 

 

 

 

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Moral duty and Moral Hazard. Woeful lack of control and supervision on pricing of pharmaceuticals by department of health…

After Thatcherism, everyone for themselves, and there is “no society” it is not surprising that British Citizens feel they can arbitrage the generic pharmaceutical system. Surely they do have a duty to report the loopholes they have exploited, and it is not “against the law”; just against their moral duty as a citizen and potential consumer. What is the opposite of rationing – profligacy?

Billy Kember reports in The Times 4th June 2016: Drug ‘profiteers’ face fines – Times investigation prompts government inquiry into £260m NHS rip-off

Drug companies that raised the price of medicines by up to 12,500 per cent could face multimillion-pound fines after the government called in the competition watchdog.

Jeremy Hunt, the health secretary, asked the Competition and Markets Authority (CMA) urgently to examine evidence uncovered in an investigation by The Times, which revealed that a select group of entrepreneurs had made a fortune exploiting a loophole in NHS pricing rules.

The companies face limited competition on long-established, off-patent drugs, which they bought from large pharmaceutical companies. By dropping the brand name, the medicines are taken outside NHS profit controls and suppliers are free to oversee “extortionate” price rises…..

You might argue that they are not ever going to be consumers, but NHSreality replies that their emergency infarct or stroke will not happen in a place or a circumstance when they have an option. The A&E departments of the Regional Health Services are safety nets for all of us.

A letter from Ian Bennett in The Times summarises nicely:

Sir, While suppliers are criticised in your report, the real blame must lie with the Department of Health for its woeful lack of control and supervision on pricing. It is not difficult to determine that some generic prices are far above those of the original patented products and also well above generic prices in other EU countries.

Many generics, marked as manufactured in the UK, are imported in bulk, repacked and packaged with a UK address. To avoid the risk of a UK supplier demanding excessively high prices, the NHS and the wholesale network should be free to obtain supplies elsewhere in the EU, under current mutual recognition procedures of product registration. This might involve some changes in labelling requirements but that would be a price worth paying to have an effective price structure for these older generic products supplied
to the NHS.
Ian Bennett
Lymington, Hants

 

Cutting pharmacists may be possible in cities, but it will be very inconvenient in rural areas. Who is off their trolley?

Rationing numbers of pharmacies may be possible in cities, but it will be very inconvenient in rural areas, unless GP restrictions are lifted. The rural “on cost” is never clearer than in pharmacies. Our town has three, but technically one could do the job of all of them…( Lack of competition may then result in diminished service.?.). None of the links below gives an indication of the increased load that might result on GPs. Actually the evidence for this is very thin, and it may be more of a fear than a reality: but politicians need to be aware that an already creaking service might implode further. Like the poor retired major, Mr Hunt and his team might well be off their trolleys..

Sean Poulter in The Mail reports 30th May 2016: Local Chemists threatened by supermarkets and Sophie Borland reports 28th May 2016: £170m cuts could kill off a QUARTER of our chemists – prompting warning of even more pressure on A&Es
Previously on 4th May Ian Strachan in the Huffington Post, opines: Why the Government Plans for Pharmacy Make No Sense

Despite the uproar BBC news reported 23rd May: Thousands of pharmacies in England ‘at risk of closure’

and Mark Whitehead in Local Government News 23rd May opines: Closure of local pharmacies would be ‘catastrophic’ for public health

Chris Sloggett in Pulse reported 23rd March: RCGP launches new initiative for pharmacists to work in GP surgeries, but this implies an expansion. Mr Hunt really wants to save money somehow, without co-payments and overt rationing. A bit on honesty might help..

 

 

 

 

GP shortages now so bad that pharmacists will be drafted in to treat patients in surgeries

Lizzie Parry and The Press Association report for The Mail 17th March 2015: GP shortages now so bad that pharmacists will be drafted in to treat patients in surgeries 

The Rationing of numbers of doctors is evident to all, and the risk is that Pharmacists might be tempted to make a diagnosis. If this happens there will be more litigation… But Dr Porter is correct, and pharmacists could take away a lot of the trivial consultations that GPs are forced to do. Work expands to fill the time available (Parkinson’s Law), and NHSreality predicts that the good suggestion will make no difference in the long run… without co-payments. It might impact badly on the litigation funds, and needs no-fault compensation to be financially “safe”..


Kat Lay in The Times reports: Pharmacists drafted in to help at GP surgeries

Pharmacists will be drafted in to GP surgeries to help combat the dearth of family doctors under plans to be unveiled today.

The proposals could see patients — particularly those with long-term conditions such as asthma or diabetes — offered an appointment with a pharmacist when they ring their surgery.

The move would cut the time patients have to wait to get an appointment and could address a current oversupply of pharmacists, experts said.

It would also combat problems caused by a rapid rise in patients on multiple drugs by using pharmacists’ expertise to ensure combinations of medicines were not allowed to become harmful or ineffective, according to the Royal College of General Practitioners and Royal Pharmaceutical Society….

Dr Mark Porter for the BMA comments:

I think this is a great idea. Despite numerous attempts over the years to integrate pharmacists into the primary care team, it has never quite worked out and their expertise remains under-used by the health service.

A significant proportion of my daily workload centres on medication and prescribing issues and it would be great to have a pharmacist to help me. Not only would it free me to see more patients, it would almost certainly lead to better medicine management and happier patients experiencing fewer side-effects.

The role of pharmacists in managing illness is less clear-cut. There is plenty that they could offer here — as many already do in high street pharmacies and on hospital wards — although it may require a change of mindset for some.

Many retail pharmacists have been brought up in an environment where evidence-based practice takes a back seat to commercial pressures. They may deny it, but why else would they peddle so many products (from cough medicines to flower remedies) that simply do not work?

Not everything needs a remedy, and not all remedies help. If they get behind that NHS mantra, pharmacists could become an even more important asset than they already are.