Prevention is better than cure

Aug 5

When prevention is better than cure, why are we spending more on the cure when the data says it’s not working? A radical approach for change or just common sense?

We are living in a time of advancing technology, communication, access to information at the touch of a button, and time saving devices. We are spending more on health and social care than ever before, so why are we getting sicker and dying earlier? Is this progress in our modern world?

I guarantee if you ask anyone if they are truly happy with their life, health, work, or social set up, they will have something to be dissatisfied with. As a society we have been through huge change in recent years; with COVID, lockdowns, political unrest, and financial hardship; there has been fear, unrest, distrust, and a general feeling of ‘dis-ease’ in our societies. We have become detached from our bodies and we do not know how to listen to our intuition. We are taking more supplements and prescribed medications than ever but the evidence shows they are not working.

In the UK the average life expectancy at birth between 2020 and 2022 was 78.6 years for males and 82.6 years for females, compared to 79.3 years for males and 83.0 years for women between 2017 to 2019, a drop of 38 weeks (ONS 2022).

The number of people living with major diseases is set to increase from almost 1 in 6 of the total adult population in 2019 to nearly 1 in 5 by 2040, an increase of 2.5 million people, a rise of 37%. 80% of this projected increase is expected to be in the over 70’s (The health Foundation 2023).

State retirement age in the UK is currently 66 years of age for both men and women, this will increase to 67 years by 2026-2028.

These statistics show that from retirement age onwards, millions of people will be living with chronic ill health, increasing the burden on an already crumbling health and social care system. More than the financial cost of these increases, is the cost to individuals’ quality of life. After working for longer, many people are faced with poor health, multiple diseases, and a lack of access to health and social care. In reality millions of people will be living the last 10 to 15 years of their lives in poor health. Is this the life we signed up for, is there another option and if there is, is it too late for change?

An article in the BMJ in 2008 stated that people aged 60 or over were given on average 42.4 prescribed items per year, up from 22.3 in 1997, this is nearly a 60% increase. A more recent study in 2019, stated that more than half of adults aged over 65 (54%) take 4 or more prescribed medications per day, compared to one third of adults aged 50-64 years (32%) (Kirzinger, Newman, Cubanski & Brodie 2019). The median number of medications per day is 7 in both men and women aged between 70-79 years and 8 in both men and women aged between 89-90 years and older (National Library of Medicine 2022).

In August 2019, Age UK called for a more considered approach to prescribing medications for the older population, after findings showed that over 2 million older people were taking 7 or more prescribed medications per day and were experiencing side effects, some severe and even life threatening, such as falls and a range of other serious harms. The report ‘More Harm Than Good’, provided evidence that prescribing more drugs isn’t always the best option. It demonstrated that medicines are sometimes being prescribed:

- In excessive numbers

- In unsafe combinations

- Without the consent or involvement of the older person concerned

- Without the support and help older people need to take them

This increase in prescribing has of course come at an increased cost. An estimated 40% increase since 2010-2011. The NHS Business and Services Authority (NHSBSA) 2023 report stated that the total cost to NHS commissioners in England for the issue of 1.18 billion prescription items in the community was £10.4 billion, an increase of dispensing items of 3% between 2022-2023, with a cost increase of 8%. (Prescription cost analysts NHSBSA 2022-2023).

The most widely dispensed drug in England was Atorvastatin, with 59 million items, the most expensive drug was Apixaban at a cost of £430 million.

Atorvastatin is from a group of drugs widely known as statins which reduce blood cholesterol levels and are estimated to reduced cardiovascular events such as heart attacks and stroke by up to 25%. The NHS, NICE, and other governing bodies in the UK strongly support the use of statins to the reduce the risk of cardiovascular events and stroke. There has been a 46% increase in the prescribing of statins between 2008-2018. There has been a cost reduction from £460 million to £96 million, a fall of 79% in 10 years. Injectable drugs are now being used but they are very expensive and studies are still ongoing (BHF 2024).

However, despite the increased use of statins, premature deaths from cardiovascular disease have risen year-on-year, and the latest figures show that it has reached 80 in 100,000 people in England in 2022, the highest since 2011, a 14 year high. The BHF estimate there were 100,000 excess cardiovascular deaths last year. The highest number of deaths have been in the most deprived areas of the country. The divide in health status between the rich and the poor is widening despite advances in medicines and treatments. The treatment of cardiovascular disease is an annual cost to the NHS of £7.4 billion, and an estimated £15.8 billion to the wider economy (Health Matters 2019).

Statins do get a bad press and there is lots of data to support their use in preventing diseases. The Alzheimer’s Society’s website discusses cholesterol and the risk of dementia and how the use of statins reduces the risk of developing dementia by up to 15% (Alzheimer’s Society UK 2024).

A study published in JAMA Neurology found that individuals who walked 9,800 steps per day can decrease their dementia risk by as much as 50% (Lang 2022)

If walking 9,800 steps per day reduces a person’s dementia risk by 50% (and is free), and statins reduce a person’s risk by 15% and cost on average £9.90 per person per month (NHS prescription charge), why are we not advocating walking as a first line preventative measure?

I suppose this question can be answered by looking at who is set to make money out of manufacturing and selling these drugs.

Let’s look more closely at Atorvastatin. One of the main brand names is Lipitor, which is manufactured by Pfizer. Interestingly, Pfizer’s patent expiration for Lipitor was in November 2011, when prescribing costs for Atorvastatin were £460 million in the UK. Following this expiration, the cost reduced significantly to £96 million. An article written in the PM360 by Pat Audet in 2012, states that Prior to Pfizer’s patent ending for Lipitor, Prizer continued to invest heavily in sales promotion for Lipitor, despite many other companies making significant cutbacks in sales expenditure across the USA. Prizer invested in physician detailing, professional journaling advertising, sampling and direct to customer advertising. Over its product life, Lipitor has been the most heavily advertised prescription drug in the USA.

A brief search online of the top 20 big pharmaceutical companies by revenue shows that Pfizer have recently been knocked off their top spot as its revenue fell by 41% from $100.3 billion in 2022 to $58.5 billion last year. Pfizer has been replaced by Novo Nordisk due to increasing sales from its diabetes and obesity treatments Ozempic and Wegovy (Dunleavy 2024).

Call me sinical but type 2 diabetes and obesity are predominantly lifestyle related diseases, surely targeting lifestyle measures is more cost effective, has less associated risks and improves overall health outcomes than any of these drugs?

Now don’t get me wrong, I am not anti-medicine. I have worked in cardiology for over 20 years and have seen the lifesaving actions of medicines and the benefits to patient outcomes, what I am against is treating the disease and not the cause.

The issue is that as a society we are reliant on taking medications to treat diseases that are preventable with lifestyle measures. It is estimated that 80% of all chronic diseases (cancer, cardiovascular disease, chronic obstructive pulmonary disease, diabetes and stroke) are driven by lifestyle factors such as diet and exercise (Golubic 2020). Just reducing loneliness can reduce emergency hospital admission. Following a pioneering study by Dr Kingston in 2013 where a loneliness clinic was set up in Frome in Somerset, there was a 17% reduction in emergency hospital admissions when there was a 29% increase across the rest of Somerset. A Danish study revealed that following a heart attack, women who were classed as lonely were 3 times more likely to die within the year compared to women who felt socially connected (Lane-Godfrey & Moss 2022). There are no drugs available that have these sorts of improvements in health so why are we not investing in more research in to the effects of lifestyle on health?

The estimated cost of treating and managing long term conditions on health care budgets in the UK in 2019 was nearly 80% (an increase of 5% from 2011) of the total gross current expenditure of £14.6 billion, that’s £11.6 billion. This is inevitably only set to rise. How do we create change in focusing on prevention and not just cure, when so many companies are making billions of pounds out of our sickness? Unfortunately, big pharma can’t charge for walking, sleeping, eating nutritious food, meditating, and having a good social connections, but I bet they would if they could.

References:

1. ONS 2021: The Office of National statistics https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/lifeexpectancies/bulletins/nationallifetablesunitedkingdom/2020to2022

2. The Health Foundation 2023

https://www.health.org.uk/news-and-comment/news/25-million-more-people-in-england-projected-to-be-living-with-major-illness-by-2040

3. BMJ 2008: The British Medical Journal

https://www.bmj.com/content/337/bmj.a1132

4. Ashley kirzinger, Tricia Neuman, Juliette Cubanski & Mollyann Brodie 2019

https://www.kff.org/affordable-care-act/issue-brief/data-note-prescription-drugs-and-older-adults/

5. National Library of Medicines 2022

https://www.ncbi.nlm.nih.gov/books/NBK532953/

6. AGE UK 2019: A more considered approach to prescribing

https://www.ageuk.org.uk/latest-press/articles/2019/august/age-uk-calls-for-a-more-considered-approach-to-prescribing-medicines-for-older-people/#:~:text=Age%20UK%20estimates%20that%20almost,taking%20at%20least%20five%20medicines