Frank Dobson, before he relinquished the position of Secretary of State for Health, finally pronounced on Relenza and gave it the thumbs-down, at least for the present. According to the Times, further clinical trials are to be carried out, this time with patients in the "at risk" groups, before the drug will be considered for National Health Service usage. For all his supposed faults, big Frank has at least stuck to his guns over this issue.
The first drug to be assessed by the National Institute for Clinical Excellence (NICE) was bound to attract much attention. The fact that the first to be reviewed was also the first to be rejected has ruffled many feathers, not least those of the drug industry barons. The petulant behaviour of senior industry figures has been childish and pathetic, with their threats to withdraw their whole research base from the United Kingdom if the Government did not allow this one particular new drug into the NHS. Whom do they think they are kidding? The NHS is simply a customer, no more and no less than a private hospital or a private individual with his or her private prescription. Medicines, we should remember, are simply articles of commerce, some of which are purchased by the NHS to assist in its care of patients. Medicines are specialised consumer goods - specialised because of the many legal controls over their production, marketing and distribution. Medicines manufacturers are merely suppliers of articles consumed by the NHS in the course of its work. Pharmaceutical companies, while being among the highest of high-tech organisations, have no more special place in the greater scheme of things in the NHS than the suppliers of other articles that the NHS uses, be they X-ray films, bandages or toilet rolls. We have, through the way in which the NHS has operated over its first half-century, allowed the drug industry to have ideas above its station and to assume that it has "power". Well, it does not, and what a relief that neither Mr Dobson nor the Prime Minister have yielded to industry bullying over Relenza.
The Relenza saga raises a number of issues. First, the Government may have been concerned about the potential cost of Relenza and taken fright, much as with other presumed bank-busters such as Viagra and beta-interferon. However, there is a much more important issue which the manufacturers seem not to have considered, and that is the horrendous workload implications of such a drug during the winter season, which is always over-busy anyway. Relenza has to be taken within 48 hours of symptoms appearing, so anyone with a sniffle might rush to their surgery for an emergency appointment. There would then be a scramble to find a pharmacy that had some in stock. Why do new drugs such as Relenza have to be prescription-only when they are first marketed? An alternative would be for Relenza to be given a P licence so that it could be supplied directly by a pharmacist, who would have a check list and appropriate training to identify a genuine case of influenza from a common cold.
Another view, to which I, and perhaps other pharmacists also, subscribe, is why do we need any more new drugs? Who actually needs them? The NHS or the drugs industry? This is not to denigrate the value of the many medicines that have appeared on the market over the past few decades, many of which have transformed the lives of countless patients, but do we perhaps have enough now? Is there really a need for a ninth beta-blocker, a 17th ACE inhibitor, or whatever? While acknowledging that the development of a new medicine takes a number of years and that there is a very heavy investment in the development process, the new drug becomes something of an unstoppable juggernaut, unless, of course, it falls at a clinical trial hurdle by revealing hitherto unsuspected toxicity. Even after marketing, many drugs are withdrawn quickly for various reasons, for example Manoplax and mibefradil. Also, has anyone working in the NHS ever been asked by the industry exactly which new kinds of medicines the industry should develop and market?
Perhaps, in these days of joined-up Government thinking, alternative ways of improving health should be investigated, rather than merely investing in the latest wonder drug. Health, while everyone's right, is to a considerable extent everyone's personal responsibility. People do have much control over their state of health, a fact which is probably unfashionable and almost certainly politically incorrect. As pharmacists, we are aware of the major contribution to a person's health that can be made simply by giving up smoking or by not starting smoking in the first place. Probably less is realised about the role of food. By this I mean the availability of good quality, cheap, nutritious basic foods such as fresh fruit and vegetables.
Many years ago there was a major campaign to persuade people to eat more fruit. There were posters everywhere, not just in the greengrocers' shops. It was a worthy and accurate campaign. Lack of fresh fruit and vegetables can lead to a poor state of health that no amount of high-tech medication will remedy. A nursing colleague told me an interesting anecdote about a young man who had a leg injury as a result of playing football. The gash would not heal, and eventually she asked him about his diet, which consisted largely of fast food with not a piece of fresh fruit or a vegetable in sight. She advised him to buy some oranges, apples or whatever fruit he liked, and sure enough his injury began to heal. "I would never have believed it," he said to my colleague. Evidence? I think so, even though there was only one patient in this trial! However, where can many people buy good quality produce at affordable prices? Not in many of the poorer parts of the country, such as inner city areas. By allowing the spread of out-of-town shopping complexes, we have created "food deserts" in which the traditional local shops have been put out of business and there is nowhere for people without access to a car to go to buy good food.
A number of ideas have been put forward for local peoples' co-operatives in which food and other essential goods could be sold cheaply to poor people living in a particular neighbourhood. However, a report of such a scheme in my local newspaper pointed out that volunteers who worked for the co-operative ran the risk of having their benefits stopped, even though they were not being paid for the work, on the flimsy grounds that they were making themselves unavailable for "proper" jobs. How silly and bureaucratic can you get? Why not encourage people on benefits to work on such schemes, thereby making available the good, fresh food that people really need and want, and improve the health of the population at a stroke? Food co-operatives of this kind could have a major public health effect, far more so than the new drugs which still seem to flood the market.
Now let us think the unthinkable. Why not allow, or even encourage, pharmacies to sell basic foodstuffs where appropriate? I occasionally do a Saturday morning locum in a small pharmacy that sells, among other things, bread, milk and cat food. Horrors, I hear you cry, how unprofessional! However, there is now no local shop and the nearest source of food is a large branch of a national supermarket chain. To reach this superstore, elderly, infirm people have to cross a dual carriageway, at some risk, so if one runs out of milk on a Saturday morning it is something of a catastrophe. Therefore, that small, corner-shop pharmacy offers a service that the local people much appreciate. Colleagues would do well to remember that the humbler things in life, such as cheap, fresh food, are as important, if sometimes not more so, than the latest high-technology wonder cures.
John Wilson is a pharmacist based in Arnold, Nottinghamshire, who has retired and now works part time