From Mr R. Gartside, FRPharmS
SIR,— Health in most "Western" countries makes up about a tenth of all productive activity. In economist speak, health is 10 per cent of gross domestic product (GDP). This was true in Britain for many years after the start of the National Health Service but over the past 10 to 20 years the British health spend has declined to about 6.5 per cent of GDP. What happens elsewhere is that it is a combination of public and private health that makes up the 10 per cent. What happens here is that the private contribution has been negligible until now.
The politicians make much of Britain having the most cost-effective health service in the world. The toilers at the coal face know that wages make up three quarters of health costs and the NHS is cost-effective because it underpays its workers. Hence the appalling staff shortages, which are probably most acute in pharmacy even though our problems do not seem to make the headlines. It is against this background that we should look at the recommendation by the National Institute for Clinical Excellence (NICE) that Relenza, the new drug for the treatment of influenza, is insufficiently effective to justify its cost and should not be allowed on NHS prescriptions. Regardless of whether the stuff works or not, this is a milestone decision.
In 10 years time, we will look back and say that this is the point where the great dream of universal free medical treatment died. Clinical freedom and judgment are to have no say in the use of this medication. The NICE (which perhaps should be renamed the National Institute for the Control of Expenditure) has decided that Relenza is too expensive in relation to its clinical benefits and, therefore, should not be used. Do not argue, just obey.
Profound changes may follow this decision. Part of the problem seems to be that general medical practitioners were worried that they would be unable to cope with the expected floods of patients (most with simple colds) demanding treatment. Since in most parts of the country it is impossible to get an appointment with a general practitioner in under three days and since Relenza treatment must be started within 48 hours of the onset of influenza, huge problems were foreseen. In reality, very few patients with true influenza are able to get out of bed to make it to the surgery, so a huge increase in the number of house visits was to be expected.
Treatment with Relenza would need a prescription so patients could not be told over the telephone to take some paracetamol and a hot drink and "sweat it out". They would actually have to be seen, diagnosed, and treated. And the cost of the drug would make a nonsense of any existing budgets.
Of course all these problems would be resolved if patients were to be treated privately. A daily private influenza clinic or home visit would offer immediate medical access and an immediate private prescription. For many people the extra expense would be worthwhile - even for freelance pharmacy locums the saving of two working days produces far more income than the expected cost.
The same private clinic and private prescriptions could also handle the demand for Viagra and holiday antimalarials (to say nothing of other black-listed drugs) and a healthy addition to practice income might well be expected. In time, well heeled patients would welcome the chance to jump the GP queue for other conditions, even for non-urgent ones. Many people already feel that their time is too valuable to waste on the present inefficient surgery arrangements and the expected cost is not an important factor.
The two tier NHS will have arrived with a vengeance. Britain will have joined the rest of the World in having a basic government safety net health service backed up by a Rolls Royce private service. Is this what we really want? It does look as though it is what we are going to get and the wise pharmacist might want to ensure that he or she will be among the beneficiaries.
R. Gartside
Beddgelert, Caernarfon