The Pharmaceutical Journal
Vol 277 No 7430 p686
9 December 2006

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Expensive drugs are cheap; it is the cheap drugs that are expensive

By John Wilson

All I want is more time with my family before I die — thus ran the headline in my local paper recently. A 40-year old man, a non-smoking father of two, was reported to be dying of lung cancer. His consultant had recommended the use of a new drug, erlotinib, a novel oral tyrosine kinase inhibitor), on the grounds that this would prolong his life by a few months. The patient’s local primary care trust had refused to pay for the drug (quoted in the newspaper as costing £1,500 per month) because the National Institute for Health and Clinical Excellence “had not approved it and it was too expensive’. According to the newspaper report, other cancer patients in the region have also been refused this drug. There is currently a long-running battle by patients to have prescribed for them seemingly expensive drugs.

My family, on my father’s side, has a long history of cardiovascular disease. However so far, thanks to making some effort, I have reached the middle of my seventh decade with an excellent blood pressure and with cholesterol levels well within the accepted parameters. I am reasonably fit and am certainly not overweight, unlike so many patients of similar age and younger who come into the various pharmacies in which I work for occasional days. However, some years ago, in an attempt further to thwart the demon that has stalked my family for generations, I prescribed for myself a daily 75mg dispersible aspirin tablet.

There have so far been no side effects or adverse reactions and, for one of the few proven prophylactic measures against cardiovascular disease, the drug is remarkably cheap. Prices vary somewhat from pharmacy to pharmacy, but the average seems to be about £1.25 for 100 tablets. Thus, for a total outlay of some £4.50, I have a year’s protection from heart disease.

What else can you buy for £4.50?

Now, what could I have spent the £4.50 on, if not aspirin? The following spring to mind:

· Four pots of tea for one at the local supermarket’s in-store restaurant

· A bottle of quite drinkable but otherwise unremarkable wine at said supermarket

· Five litres of petrol

· Two pints of lager (and perhaps a packet of crisps)

· A double-cheese grease-burger and fries (ugh! — no thanks)

· Four journeys by bus (assuming that I had forgotten my “wrinkly pass”).

Other such items may occur to readers. This, then, is the extent of my financial sacrifice in order to procure peace of mind for another year, at least on the heart disease front.

Recently, I did a single day’s locum at a large, busy but well staffed and well organised pharmacy. It was their “quiet day” but we still dispensed 472 items. Of these, I counted 27 items calling for 75mg aspirin. That is, one in every 17 prescription items dispensed that day was for aspirin. I realise that a study of one day in one pharmacy is not a scientific sample, but experience indicates that it was not atypical. Of the 27 items for aspirin, only one was for the enteric-coated form, and two were for more than a month’s supply. Thus, 24 of the 27 were for 28 aspirin 75mg.

Thinking about this, I referred to the August issue of the Drug Tariff. I was surprised to see that the reimbursement price for 75mg aspirin in packs of 28 was £1.09. The dispensing fee, I noted, was 90p and the container allowance 3.24p. Therefore, the cost to the NHS (ie, the taxpayer) of a month’s supply of 75mg aspirin is currently just over £2. That comes to a little over £54 for the aspirin prescriptions that I dispensed on that single day. This is for one pharmacy on one day. How much might the NHS spend on aspirin in the whole of England in a year? I found the answer on the Department of Health website. In 2005, the total number of items for aspirin in BNF subsection 2.9.0 (anti-platelet drugs) came to 25,883,300, at a total net ingredient cost (NIC) of £28,966,000. However, the NIC is not the only cost to the taxpayer. Dispensing fees and container allowances (at August 2006 prices) on the dispensed items for aspirin would have amounted to £24,133,589. In all, therefore, the NHS would have spent a staggering £53,099,589 on prophylactic 75mg aspirin in England alone during 2005.

Is this figure static, or has the prescribing of prophylactic aspirin increased over the years? A further inspection of the DoH website gave data for items and NIC for prophylactic aspirin for the years 1998 to 2005. The data indicate that the number of items has increased by 121 per cent and the NIC by 338 per cent over those eight years. I am aware that some of the increase in item numbers may be due to a move from two or more months’ supply to a 28-day supply, and generics prices have certainly changed over the eight years, but even allowing for this, the increase in prescribing of aspirin is enormous.

Now, on what could the NHS have spent £53m in 2005, if not on aspirin? Some expensive drugs, for a start. This sum could have provided:

· Trastuzumab (Herceptin) at £20,000 per annum for 2,650 women with breast cancer

· Imatinib (Glivec) at £18,275 per annum for 2,900 patients with chronic myeloid leukaemia

· Bexarotene (Targretin) at £17,100 for 3,100 patients with skin manifestations of cutaneous T-cell lymphoma

· Erlotinib (Tarceva) at £15,888 per annum for 3,335 patients with lung cancer, such as the gentleman referred to in my local evening paper

If we look at salaries, £53m would fund for one year:

· 2,650 staff nurses at an average salary of £20,000

· 1,767 hospital pharmacists at an average salary of £30,000 (somewhere within Agenda for Change bands 6 to 7)

· 855 GPs at a salary of £62,000 (roughly the mid-point of their new salary scale)

The above figures, both for drugs and salaries, are astonishing.

People should look after their own health

Recently, in a major speech in Nottingham, the Prime Minister stated that people should be more prepared to look after their own health so as to place fewer burdens on the over-stretched NHS. He was, I understand, mainly referring to levels of obesity, smoking, lack of exercise and excessive eating of nutritiously poor “junk” food. However, should this concept not also extend to the purchase of a simple, but highly effective, prophylactic drug such as 75mg aspirin?

At the recent British Pharmaceutical Conference, it was reported that, since the reduction of the prescription charge to £3 per item in Wales (less than half the charge in England) there has been a reduction in the over-the-counter purchasing of paracetamol and a concomitant increase in prescriptions for this drug. So, yet another cheap drug is being increasingly prescribed.

It would appear to me that it is the cheap drugs that are expensive to the NHS, so we cannot afford the expensive drugs. It is high time that we had a proper debate about what the NHS should provide and what it is reasonable to ask people to purchase for themselves.