The needs of the many...

How generous are you?

Would you, for instance, be prepared to put your health at risk in order to prevent a total stranger having a heart attack? How about if that heart attack is, at present, purely hypothetical and may not happen for years, if at all?

Increasing numbers of patients in this country have been put on statins in the last decade, amid spiralling obesity and more aggressive prescribing of the medications by family doctors, whose pay is linked to take-up of the pills among their patients.

The pills, which cost the NHS less than 10p per patient per day, are now the most commonly prescribed medication in Britain, with eight million people on some type of anti-cholestoral drug. 

So convinced are the hard-line advocates of statins that they would like to see them routinely prescribed for the general population.

Some cardiologists have suggested they should be automatically prescribed to all patients from the age of 50, but others have said they are “disturbed” by the trend to dispense the pills ever more widely, exposing millions to potential side-effects.

But the benefits of statins outweigh the risks; the scientists have said so.

Research has suggested up to one in five patients taking the drugs suffers some kind of ill-effect, including muscle aches, memory disturbance, cataracts and diabetes.

That's a pretty nasty collection of  potentially serious and irreversible health problems, particularly if you were in perfect health before you started taking the pills. As new, improved versions appear on the market, more side-effects are bound to follow.

Atorvastatin was linked to one extra case of diabetes for every 160 patients treated.

Most serious of all is the widely-ignored problem of statin side-effects masking the symptoms of life-threatening conditions. All those muscle pains, kidney problems, headaches and jaundice could be the effects of the statins, but they might also be indications of serious disease.

By the time your doctor has swapped brands, changed the dosage and finally decided it wasn't the statins after all and he really ought to run some tests, it may well be too late to do anything about it.

But the benefits of statins outweigh the risks; the scientists have said so.

This is essentially the Trolley Problem - you can save five people from a runaway train by sacrificing one man. The Utilitarian principle says this is justifiable, even if he would otherwise have led a long and healthy life.

But in this case, we don't really know whether the train would actually have hit the five people, or killed them outright even if it did; according to the author of a recent book on statins (quoted in Saga magazine):

If you’re at high risk of heart disease or stroke and you take a statin for 30 years, you’re likely to live an extra nine months.

If that's true, it hardly seems worth risking the debilitating side-effects that, if universal prescription for the over-50s went ahead, could affect millions of previously healthy people, let alone the premature deaths from undetected cancer.

But the benefits of statins outweigh the risks; the scientists have said so.

Statins are bad for the blood pressure

Or mine, at least. I do so hate starting the day in a bad temper.

Unfortunately, the first news article to meet my eye today was on prescribing statins for all - a subject about which, as regular readers will know, I have strong feelings - though it goes some way to mitigate the fury that the Telegraph article has over 500 comments, the vast majority of which condemn the idea.

Aside from a deep mistrust of blanket prescription in general, my main objection that the many known side-effects of statins - liver problems, kidney failure and muscle weakness to name but a few - can mask the effects of serious disease; we will never know how many people have suffered as a result of doctors dismissing their symptoms as statin-related until it was too late, but I certainly have no intention of joining their ranks.

The pill-pushers insist that medicating a whole population is justified because 'the benefits outweigh the known risks', which may well be true - though it's scant comfort for those who are effectively killed off in order to protect ten strangers from potential heart attacks - but what of the as yet unknown risks associated with long-term medication for all?

By the time I recovered my equilibrium, the eminently sensible Longrider had got there first with a post that says all that needs to be said on the matter, so I shall confine myself to a quote from the BBC's version, in which Prof Colin Baigent makes an asymptote of himself:

"We've been taught over the years that high cholesterol is the thing that matters; you mustn't have high cholesterol. But what we've actually learned is that, whatever your level of cholesterol, reducing it further is beneficial."

Now that's what I call marketing!  However healthy you are, they want you to join the happy band of prescription junkies and be grateful to them for preventing the heart attacks you were never going to have.

Margin for error

A member of Clan Macheath had a blood test last week as part of a routine check-up. Returning to the surgery for the results, she was told she had 'a risk factor of 15%'.

The nurse seemed surprised to be asked for an explanation; "Look, it's here on the chart: your cholesterol gives you a risk of 15%, see?"

"Yes, but a risk of what, exactly?"

Turns out it's a risk of dying of a heart attack in the next ten years. Now it's not the easiest thing to express without giving the lady's age, but generally speaking this looked like not unreasonable odds of survival (her words, not mine); in any case, like most well-educated people, she knows that medical statistics - like boiled eggs - are best taken with a substantial pinch of salt.

But the nurse had not yet finished; under the circumstances, she said, she would recommend a course of statins. Not a good move; the patient is firmly opposed to blanket prescription and has a particular aversion to the idea of statins - and she's not the only one (see my post Statins for all and a death sentence).

The nurse was clearly disappointed; "Then we'll just have to try and manage it through diet". Manage what? The cholesterol reading was well within normal parameters; either the word 'risk' seems to have triggered a knee-jerk response or the 'statins-for-all' movement is alive and thriving in the hands of blinkered zealots.

One thing that interests me here is that our relative was not told whether to fast before the test. This is presumably because a study in 2009 found that 'cholesterol measurements are at least as good - and probably somewhat better - when made without fasting'.

But if that is so, why does the NHS website - reviewed in 2011 - still clearly advise 'Do not eat anything and only drink water for 10-12 hours before having blood cholesterol tests'? Are doctors, in fact, actively seeking raised readings by ignoring this advice?

This suggests at least some difference of opinion - and implies that the cholesterol test is rather more of a blunt instrument that those acting on its results would like us to believe. Given the very real possibility that statin side-effects will mask the symptoms of serious illness, I would question the ethics of prescribing on these terms.

The complexity of the human body means that diagnosis is not a exact science; to reduce it to box-ticking and percentages on a chart is to act under false pretences and with a dangerous complacency.

Statins for all and a death sentence

Professor Sir Nicholas Wald said prescribing cholesterol-busting statins and blood pressure pills based on age alone would be much easier and quicker than the current system.

However, concerns about the side-effects of the drugs mean that the proposal would be controversial. [...]Addressing the concerns, Sir Nicholas said the benefits would easily outweigh the risks.

Once upon a time, there was a fit and healthy man in his early seventies. At his GP's request, he visited the surgery for a check-up, where he was poked and prodded in the customary manner before being told that his BMI and cholesterol levels were 'rising' - not 'high' or 'elevated'; just slightly above the previous reading.

The GP prescribed statins - this was at the beginning of the statins-for-all campaign as media doctors got on the bandwaggon - and the man, being a cooperative sort, obediently took them.

This man had a healthy lifestyle - didn't smoke or drink, ate well and took plenty of outdoor exercise - and was seldom ill, so when he started to feel unwell soon afterwards he went back to the doctor.

'Side-effects, that's all', said the doctor, and changed the brand of pills. Things were no better, so the man went back again and asked the GP to investigate. 'No need', said the GP, 'It's just side-effects of the statins' and the pills were changed once more.

The symptoms multiplied and still the doctor refused to carry out further tests - 'It's just a case of finding out the correct dose'. For over a year, things went from bad to worse until, in desperation, the man sought a second opinion.

The second opinion was unequivocal - aggressive cancer, now so far advanced that there was nothing left but palliative care; with supreme irony, detailed scans showed that the patient's cardio-vascular system was in excellent condition. The statins, now replaced by increasing doses of morphine, had been completely unnecessary.

This cannot be an isolated case, yet I have seen nothing in the concern expressed about side-effects mentioning that they may mask the symptoms of cancer and other serious conditions. I suppose that is one of the risks that is 'easily outweighed' by the benefits of statins for all.

That's the trouble with the way Sir Nicholas and his kind think of patients; as figures on a chart - one unnecessary death from cancer set against the prevention of several heart attacks constitutes an acceptable risk.

Mathematically that may be true, but I wonder if he - and his family - would still think so were he the one?

One for the Road to Perdition?

Poacher turned gamekeeper Frank Skinner has launched a vehement and interesting attack on alcohol consumption in today’s Times. As one might expect from a former problem drinker, he insists that Britain has a dependency culture and that intervention is essential:

"the BMA should forget about cosmetic changes, such as banning advertising and happy hours, drop the niceties, come down at least as hard as it did on tobacco and say what needs to be said: alcohol is a dangerous drug dressed up as a warm and reassuring companion."

Of course, coming down hard on tobacco hasn’t exactly stamped out smoking, as a walk down my local high street will amply demonstrate. In fact, I should hazard a guess that the same people whose alcohol consumption gives cause for concern are those whose health is being undermined by their smoking and eating habits.

Here in the tavern we are generally as politically neutral as possible (saves arguments with the regulars) but should Mr Skinner turn up for a lime juice, we might find ourselves getting in touch with our inner libertarians:

"We can’t trust the people to decide for themselves because their dependency — often not readily apparent and so easily denied — obviously clouds their judgment. We need the BMA to provide impetus for a great national sobering-up."

Nobody would deny that there are serious alcohol-related problems in this country and that there is a risk that excessive consumption is seen as normal. However, to suggest that we are all, to some extent, alcohol-dependent and in need of regulation is rather too like the prescription of statins for all because some people are overweight.

If Frank Skinner does drop into the Tavern, I sincerely hope Ambush Predator will turn up for a chat; the ensuing debate should be well worth watching.

A Cancer Specialist Within Two Weeks?

Let's give a hearty two-and-a-half cheers for the guarantee of seeing a cancer specialist within two weeks - and a trip to a private consultant if the NHS can't do it.

Except that the 'pathways' in current use by GPs - accessible via NHS Direct - already state that a patient suspected of having cancer should be seen within 2 weeks. Yet again, New Labour make a song and dance about an 'initiative' that's already happening.

Ah, you may say, but now it's a concrete guarantee - infallible, surely? Well, no, actually, because you have to be 'suspected' of having cancer before they let you in through the gates, and that means having a GP who can spot the signs.

Don't get me wrong - there are many excellent GPs out there, my own included. Unfortunately every system has its flaws. As regular readers will know, members of my family have had less than ideal treatment in the past. The scenario goes something like this.

You visit your GP with a problem - or even just for a check-up - and he/she puts you on statins/HRT/steroids (despite your misgivings), citing endless studies (but not PCT targets). Your symptoms worsen but your GP puts it down to side-effects and changes the dosage/brand; this can go on for months.

You repeatedly ask for cancer tests, but are told firmly that it won't be cancer - you're not obese/sedentary/a drinker or smoker (and your GP has a shaky grasp of probability - he/she tells you that if 97% of sufferers are obese, your chances of having cancer are 3%).

Eventually you find another GP who agrees to do the test - and you win first prize: an instant trip to Oncology with added chemo and an emergency operation thrown in. And here's the kicker; you still fall within the 2-week rule because the first GP never 'suspected' it was cancer.

10 Ways the NHS is Killing People

Over the past few years, three close relatives of mine have been seriously ill. In each case, their chances of survival were seriously impaired by a catalogue of mismanagement and inefficiency. In particular, the delays in diagnosis and treatment, if other patients have had the same experiences, could be significant in the UK’s shameful cancer survival statistics.

'No shows' at consultant appointments cost the NHS many thousands every year. To the best of my knowledge, nobody has ever fully researched why patients miss appointments; they could start by asking members of my family, who, despite their assiduous efforts to attend every appointment, have experienced the following:

1. A consultant’s appointment letter sent to an empty house – the ‘client’ being a long-term in-patient in another department of the consultant's own hospital at the time. 

2. Several urgent appointment notifications received some days after the appointment date because ‘the hospital post-room only operates one day a week to save money’.

3. A vital letter which the consultant never saw – according to subsequent enquiries, it was opened by a secretary who decided it was not urgent and put it straight into the filing cabinet.

4. An urgent letter from a consultant which did not reach the patient in time because his secretary took two weeks to type it up. 

5. The receptionist who failed to mark the patient as having arrived for an appointment – so the consultant went home without seeing her. 

6. The receptionist who gave a cancer patient an appointment (requiring an 80-mile round-trip by taxi) on the consultant’s day off.

Of course, you have to get a referral to the consultant in the first place, which is not easy when you are faced with:

7. The GP who missed a cancer for 2 years, despite textbook symptoms, because the non-smoking, non-drinking 7-stone patient ‘didn’t fit the profile’. 

8. The GP who dismissed advanced cancer symptoms as side-effects of HRT, saying ‘if people bothered about side-effects, nobody would ever take anything’. 

9. The GP who refused for 5 months to carry out a PSA test (an indicator of prostate cancer) because, he said, the patient was merely experiencing 'normal side effects from statins'– when the test was finally done, the cancer was too far advanced for treatment.

And then again, there’s the careless lack of attention to detail:

10. The consultant who, we can only assume, gave a diagnosis of cancer to the wrong patient. On checking in late (after traffic delays), my relative was told by a puzzled receptionist, 'You've already had your test results; your name was ticked off the list when you went in twenty minutes ago'.

All of the events described here have happened to members of my family in recent years and have contributed to at least one premature death. I’m not going to say any more on the personal side here, but I have promised them that I will use any means in my power to publicise what has gone wrong while safeguarding their anonymity.