Two weeks ago, the BMJ published research that reinforced the overwhelming evidence that the United Kingdom’s National Health Service should continue to be publicly funded and publicly provided.

A nationalised health system provides better quality care at a lower cost. Conversely, a commercialised healthcare system does the opposite, as best demonstrated by the United States which has the largest healthcare expenditure of the industrialised nations with the worst health outcomes. A marketised healthcare system ensures greater vulnerability to exploitation of the rich and the poor.

‘The former to over investigation, unnecessary intervention, higher costs and dubious treatments, and the latter to lack of necessary care.’

So, why is the NHS failing to adhere Labour MP Aneurin Bevan’s founding principles of universalising the best health for all and improving the mental and physical wellbeing of the population?

Perhaps the most important factor is the system’s increasing inability to ensure that the medical profession are adhering to the principles of real evidence-based medicine. This is where doctors combine their clinical knowledge, best available evidence, and (most importantly) take into consideration individual patient preferences and values in order to treat illness, manage risks, or relieve suffering.

It doesn’t take a rocket scientist to understand that if doctors are making clinical decisions based on biased or commercially corrupted information, at best it will lead to sub-optimal outcomes and at worst cause harm.

With rare exception, the results of pharmaceutical industry-sponsored clinical trials exaggerate the safety and benefits of their products leading to lack of fully informed consent. This is further compounded by the fact that due to ‘commercial confidentially’ the raw data from clinical trials is rarely independently analysed.

Regulators such as the US FDA, the MHRA in the UK, and the TGA in Australia take a large proportion, if not most, of their money from industry introducing a potential bias into the veracity of clinical guidelines.*

Only two days ago, Medscape (a prominent website for medical education) reported that Britain’s All Party Parliamentary Group for Pandemic Preparedness have called for an investigation into the UK’s drug regulator the MHRA for being a ‘serious risk to patient safety’.

The consequences of commercial influence on health policy for society are devastating. Prescribed drugs continue to be one of the leading causes of death globally after heart disease and cancer.

The Choosing Wisely campaign was instigated as a joint initiative with the BMJ in the UK by the Academy of Medical Royal Colleges in 2015. It was aimed at addressing this public health crisis of overdiagnosis and overtreatment to enhance quality of care. Their call to action aimed to enhance patients’ understanding of the potential harms of medical interventions and help them accept that doing nothing can often be the best approach.

For example, patients should be encouraged to ask questions such as: Do I really need this test or procedure? What are the risks? Are there simpler safer options? (Such as lifestyle changes.) What happens if I do nothing?

The Academy also called for educating doctors to have a better understanding of medical literature and ensure that they conveyed information to patients on the benefits and harms of interventions in a more ethical and transparent way. Almost a decade later, there is no evidence of any of the Academy’s key recommendations being implemented into clinical practice.

Shared decision-making has the potential to save the NHS billions, and improve patient satisfaction and outcomes. It would, however, cause a considerable dent in the profits of the pharmaceutical industry because patients, when fully informed, tend to choose fewer treatments.

Cholesterol-lowering drugs are a trillion-dollar industry, but how many patients with a less than 20 per cent risk of a cardiovascular event in the next decade (the majority prescribed globally) are explicitly told by their doctor that the absolute benefit of taking a statin is approximately 1 in 100 of preventing a non-fatal heart attack or non-disabling stroke with no mortality benefit over a 5 year period?

Drug companies have a fiduciary obligation to produce profit for their shareholders, but they have no legal obligation to give you the best treatment. As Cardiologist Peter Wilmshurst points out, the real scandal is that many of those with a responsibility to patients and scientific integrity (doctors, academic institutions, and medical journals) collude with industry for financial gain. The downstream effect also leads to a corporatised culture within healthcare where shortcomings in ethical standards can usurp patient needs.

Prior to exposing a cover-up by the Department of Health and NHS England of ambulance delays (including that which contributed to my father’s death) in the national press, I informed a training program director in Cardiology of what I was about to do, to which he replied, ‘I would advise you not to, you make yourself enemies and there is no benefit to you.’

Medicine is hierarchical and obedient. If large sections of medical leadership don’t start to adhere to the highest standards of ethical conduct and evidence-based medicine our patients and healthcare workers will continue to suffer unnecessarily. If patient outcomes are optimised, there is better job satisfaction, increased morale, and less stress on health services. The elephant in the room is that to fix healthcare, the medical profession itself needs to start to take a really good look in the mirror.

Dr Aseem Malhotra, MBChB. Consultant Cardiologist.

*(Editor’s note: the TGA insists that they remain strictly independent.)

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