Comment

Pharmacy and national policy on pharmaceuticals

By David Taylor

The relationship between pharmacy and pharmaceutical companies is not always an easy one. The profession and the industry sometimes seem joined in opposition rather than partnership. But in reality their interests are closely intertwined. Both are stakeholders in modern medicines, and the promise that research into new treatments and other bioscience innovations offers for the future. Both have a common interest in the appropriate regulation of the pharmaceutical sector, which balances public interests in factors such as convenient access to effective medicines and safety from risks.

As a nation, Britain, too, is an important stakeholder in the pharmaceutical and allied sciences. Relative to domestic spending on medicines, no other major economy benefited as much from their production and sale as did that of the UK in the period 1950–2000. Without the earnings activities like pharmaceutical research generate for the country, good public services would be harder to afford.

An integrated national strategy?

The Pharmaceutical Journal (December 23 and 30, 2000, p905) recently reported a paper by Professor Tom Walley and colleagues from Liverpool and Birmingham, which called for a single national policy on pharmaceuticals. It highlighted the conflicts that exist between goals such as limiting National Health Service spending on medicines, and promoting greater investment in pharmaceutical research.

The paper suggested that current policy-making in the pharmaceutical arena is too fragmented, or "balkanised". The proposed solution involves building on the work of the National Institute for Clinical Excellence through, for example, centrally funding its recommendations on the appropriate use of medicines. Any extra costs, Walley and his co-writers argued, could be met through new price controls on NHS medicines, or by "generic substitution by pharmacies".

However, the same issue of The Journal (p905) also reported concerns — expressed in a meeting organised by European Commissioner Erkki Liikanen — that the pharmaceutical industry in Europe is falling behind that of the United States. Such observations raise many questions, including, "Are pharmacy’s most valuable contributions to health in the 21st century likely to be in the area of cost medicine containment?", and "Are calls for more centralised approaches to controlling pharmaceutical costs in the UK based on a rational assessment of the available economic, sociological and clinical evidence?".

No simple solutions

Realistically, the answers to such questions cannot be simple or tidy. In complex, multifaceted areas of social and economic policy single "right" answers are rare. One of the hardest facts for many commentators to face is that in much of life it is only possible to establish robust evidence-based policies in retrospect. "Muddling through" is in practice often the best that can be done, which is why plural market-based systems frequently outperform the efforts of central planners to improve community welfare.

Other facts which may be difficult to accept include:

There is no longer an independent British pharmaceutical industry Production of most generic and many other medicines has already moved abroad, and research-based companies now operate on a trans-national basis.

The UK's pharmaceutical sector controls have served the NHS and the country well since the 1960s. But radically new regulatory strategies may now be needed Suggestions that the Pharmaceutical Price Regulation Scheme guaranteed company profits by allowing them to put up prices automatically are untrue, as are claims that more generic prescribing could — subject to patent expiries — generate significant new NHS savings. Yet the future challenge for Britain has more to do with accepting European/world prices for medicines than creating new local controls. The UK, as one of the world's richest nations and leading beneficiaries of pharmaceutical research, must not expect to be subsidised by the rest of the world.

Health service users are becoming better informed, and less easily deflected from pursuing their best interests Professor Walley and his colleagues point out that empowered patients are likely to demand new and expensive treatments when they decide they need them, which those responsible for NHS rationing decisions may not wish to pay for. If the divergence between what service users want and judge is affordable and what the public sector will supply grows, systems such as the NHS would — notwithstanding recent moves to improve funding and standards — ultimately fall into disrepute. Health care professionals also need to be aware that incentives to minimise service costs can be just as corrupting as incentives to maximise private profit.

Pharmacy as the honest broker

One possible future for NHS pharmacists is to concentrate on working to enforce low cost medicine supply strategies. Where these are genuinely consistent with what is best for individual service users, there can be little doubt that this is a valuable and ethical role. But alone it may not be enough to ensure the future survival of pharmacy.

Further, decisions which involve sacrificing the interests of individuals for what is claimed to be the greater benefit of the overall population are always open to question. Weak, uncritical, approaches to implementing cost-driven recommendations on medicine use (based on the often fallible insights offered by health economics in its current state of development) and keeping within arbitrarily set pharmaceutical budgets could result in pharmacy becoming seen as working against the true interests of patients. It could also speed the concentration of activities like pharmaceutical research in the US.

Effective health care provision is about saving distress, rather than money. And creating national wealth demands much more than curtailing spending.

These truths offer an alternative vision for pharmacy in the future. It combines critical cost awareness with a commitment to making the best possible clinical choices in each individual case, and which values the likely future contributions of enterprises like global pharmaceutical companies consistently with the present achievements of institutions such as the NHS.

For pharmacy and pharmacists, becoming the honest broker between other stakeholders in the discovery and provision of medicines will not be a comfortable process. It will require the profession to play a more questioning part in policy determination at all levels, and involve its members in living with ambiguity rather than working to implement established rules. It will also demand making personal judgments without the the pseudoscientific pretence that "objective" research — as distinct from the fragmented processes of political and wider social debate — can determine which resource allocation choices are most acceptable in any given situation.

Yet in return for having to accept increased risk, taking a more active role in a less paternalistic, more consumer requirements focused, system of medicines regulation and supply could well offer pharmacy its best chance of not merely sectional survival, but true relevance to public health improvement. The ultimate prize is a chance to serve to the best of the profession's members' abilities the interests of patients in both good care today and innovation for better health tomorrow, in ways which earn enhanced respect from the community as a whole.