The Polypharmacy Challenge Blog
Polypharmacy perspectives: the challenge for general practice
This is the third post in our series hearing from different perspectives on the polypharmacy challenge. Here, Julian Treadwell questions whether the prominence of evidence based medicine in primary care has inadvertently pushed out the needs of the individual doctor and patient.
Polypharmacy is a deeply complex area of my everyday practice as a GP. My personal experience as a GP says something about how we have got to where we are now.I graduated in the mid-1990s when Evidence Based Medicine was in its ascendancy. A core part of GP training was ‘critical reading’ and the understanding of how research evidence should inform the decisions we make with individuals. Even back then I remember having a conversation with my trainer about an imaginary future where "almost everybody would be taking a statin". And another where we wondered if a number needed to treat (NNT) of 30 for drugs to prevent osteoporotic fractures was in fact ‘good’ medicine.
Over the following decade, Evidence Based Medicine evolved into a more prescriptive enterprise. Leading the agenda, and our practice, were National Service Frameworks setting national standards of care in priority areas, guidelines advising how healthcare professionals should care for people with specific conditions, and Quality Outcomes Framework (QOF). These initiatives did much to improve dissemination of knowledge and standardization of care. I turned into an enthusiastic 'preventer' and ran our practice’s cardiovascular clinic, enthusiastically (and looking back, rather aggressively) treating hypertension and high cholesterol as well as managing established cardiovascular disease.
After several years of this, life gradually started to feel uncomfortable. Along the way I was beginning to wonder whether we were losing sight of the individual patient before us. Most of my older patients were taking multiple medications and much of my time seemed to be taken up wrestling with the minutiae of chronic disease management and risk factor modification: the blood tests, the side effects, the piles of repeat prescriptions to check, the recall management systems. Here was a mounting treatment burden, not just for patients, but for healthcare staff and systems too. Where had the time gone to talk to people about what they really wanted?I then discovered the Preventing Overdiagnosis and Too Much Medicine movements which prompted me to re-examine the evidence behind our practice. Whilst many of the treatments I had prescribed to my patients were very helpful, I was alarmed to discover that some of the treatments contributing to this ocean of polypharmacy had only very small degrees of absolute potential benefit for an individual. The evidence for some treatments was based on quite specific trial populations, despite the treatments being offered to a broader population in practice. Much of the seemingly unstoppable rise of population multi-morbidity was in fact due to lowering of diagnostic thresholds with ‘new’ starting points based on the first hint of risk increase, or variation from the average. And of course no group was more affected than older people.
This problem is now well recognized; three great publications on polypharmacy from the King's Fund, NHS Scotland and NHS Wales in 2012 and 2013 eloquently describe the state of play and emphasise the difference between 'appropriate' and 'problematic' polypharmacy and the importance of considering risk and benefits of treatments from the range of options. Last year, NICE published it’s multi-morbidity guideline, which I’m pretty sure, was the first guideline to explicitly say, and even encourage the non-adherence to other guidelines. NICE chair, David Haslam (a GP by background), launched the guideline at the 2016 RCGP conference in Harrogate with the question “What does ‘good’ look like in the management of multi-morbidity? Answer: Not taking eight guidelines and adding them all together.” We also have the Academy of Medical Royal Colleges developing its Choosing Wisely project; encouraging and supporting clinicians and patients to make more nuanced decisions about their health care, based on evidence and ensuring decisions are consistent with patients’ values. NICE have also been leading a Shared Decision Making forum over the last couple of years and hopefully, in partnership with NHS England, will be developing better decision aids and resources to help with everyday practice.
So, it is an exciting time. It seems to me that there is consensus about where we’ve gone wrong and what we need to do to make things better. The theory is well nailed down. The change in real world practice however will be much more challenging, with barriers to overcome and new skills to be developed.
For clinicians, this will require an improvement in our access to and understanding of the evidence underpinning our treatment options, and developing skills to manage choices as well as feeling we have real permission to individualise care in a context of medico-legal concern.
For patients, there will be the good news of being offered more choice and control of one’s treatment. But this too will come with a new responsibility and, for many people, the challenge of being presented with choices based on abstract future ideas of chance of benefit versus possible harms. Patients will be expected to take into consideration complex concepts such as risk status and choosing between lifestyle choices and medication. Many will still want to be told what to do by a trusted healthcare professional. We will have to work out how we resolve the dilemmas in that scenario.With all this in mind, it’s no wonder that often it has felt easier to just do what the guidelines tell us.
About the Author
Julian Treadwell is a General Practitioner and an NIHR In-Practice Fellow at Nuffield Department of Primary Care Health Sciences, University of Oxford. He co-founded and is Vice-Chair of the Royal College of General Practitioners Standing Group on Overdiagnosis and sits on the steering committee of the Academy of Medical Royal Colleges Choosing Wisely initiative. He can be found on twitter @JulianTreadwel1