The Pharmaceutical Journal
Vol 280 No 7487 p115
2 February 2008

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Whose drug is it anyway? Should the public be taking the NHS reins?

By John Minshull

Allocation of NHS funding has always been and will continue to be an integral feature of the UK political landscape. Yet no decade throws at this service the same problems as the last, and constant review of services is essential to ensure the NHS meets the expectations of each generation.

The NHS was set up in 1948 to ensure that everyone, regardless of wealth, could receive life-saving treatment without having to worry about the financial implications. Since then, it has been realised that providing medical prophylaxis is an effective way of maximising finite resources.

Reducing morbidity led to large extensions to people’s lives; since the foundation of the NHS, average life expectancies have risen by about 11.1 years.

But it has been a victim of its own success: increasing age begets increasing risk of serious illness, which too must be treated within the NHS remit. The incidence of cancer, for instance, rises 60 per cent for men and 45 per cent for women from 65 years to 75 years and older.

In the same time that incidence of treatable diseases has increased, the number and cost of drugs has also increased. Since 1996, the number of NHS prescriptions dispensed in England has increased by 55 per cent, whereas the cost of these prescriptions has increased by 60 per cent. This is despite a general increase in generic prescribing (51 per cent in April 1994 to 83 per cent in September 2006).

The ability of PCTs to cope is repeatedly tested by the introduction of high-cost treatments that compete for limited resources. Many organisations have vested interests as to where healthcare costs should be directed. Patient groups, tabloid journalists, issue politicians and the pharmaceutical industry work alone or in tandem to influence the political sphere within which budgets are decided.

It is the naive expectation of many that the existence of compounds with the potential to extend (or save) life is enough to ensure treatment. Limited resources make it difficult for such an enormous organisation always to meet this expectation while rationally allocating money to ensure maximum benefit for patients.

In May 2002, the National Institute for Health and Clinical Excellence recommended Herceptin (trastuzumab) be used only to treat advanced stage breast cancer. In 2005 a public campaign resulted in the agreement to treat suitable candidates with early stage breast cancer.

Since this breakthrough, patient groups have taken great interest in allocation of drug budgets and the politicisation of the NHS has come under further scrutiny. As parties approach the issue from opposite angles, it is easy to understand why patients feel that denial of a £15,000/year treatment in favour of a £100/year “scientifically” proven equivalent is comparable to placing a price on life.

To combat this, some patients wish to pay for portions of the treatment themselves; the concept of “top-up healthcare” has entered the debating arena.

At first glance, allowing patients to pay for the aspects of treatment that would otherwise have to be denied seems a sensible way of balancing constrained budgets against access to care. However, where should the patient’s contribution end and why, in a supposedly equitable system, should wealthy individuals fare better than those less well off?

Pharmacists must also consider the risks involved when patients fund their own treatment. Individual trusts’ medicines policies require that all drugs be purchased and distributed via the hospital’s pharmacy department. This way, pharmacists are able to verify the integrity and suitability of the items purchased.

With patients paying for medicines individually, the more discerning among them may want to influence the source and price. Will pharmacists be able to comply if the patient has already negotiated a price with a particular wholesaler? What happens if the pharmacist goes on to question the integrity of the product supplied?

Actual costs to the patient could quickly spiral out of control. If the patient suffers from extensive side effects due to this treatment, should he pay for associated costs? What if his stay in hospital is, as a result, extended? Or if there is uncertainty over which medicine is responsible for any adverse events: who should pay then?

Perhaps a patient’s hospital stay will be greatly reduced compared with the norm: will this qualify him for a refund?

Also, when a new drug or medical device enters routine use, there are inevitable administration and training needs. The medical team will need to know how to integrate this treatment into the present regimens. The pharmacist must ensure he is competent when working with the drug and adequate protocols are in place to ensure the safe delivery of the medicine.

The nursing staff will need training to administer the drug and ensure they are able to react appropriately to any new health care needs surrounding treatment. It is easy to see how dangerous it could be to allow patients to take a heavily weighted role in the allocation of healthcare resources without the training or experience that all healthcare professionals benefit from.

On the other hand, why deny patients the chance to take an active role in their treatment? It is well acknowledged that by including patients in treatment decisions we can ensure good compliance and acceptable outcomes.

Despite the integrity of the principles underlying the NHS, equality of care does not extend to denying people a chance to life that lack of treatment may otherwise rob them. Consumerist aspects are being introduced into other areas of the NHS (eg, “choose and book”), so why not allow patients to augment their drug treatment when money allows?

By permitting patients to pay for elements of their own therapy, primary care trusts can prevent future costly court cases and can guiltlessly relinquish responsibility for all but the most cost-effective treatment options. This will ultimately free funds to ensure treatment can be spread as widely as possible, safe in the knowledge that patients are not being denied access to expensive, life-prolonging treatment on grounds of inadequate public funding alone.

The issue of top-up healthcare has prompted people to ask: “Whose drugs are these, anyway?” Should allocation of health care costs be left to ministers and health economists who are able to see the global picture and, therefore, ensure appropriate funding across the nation, but fail to understand the emotion of a local community?

Should PCTs be allowed to reign reverentially over local communities, denying access to treatments they do not consider cost effective enough? Perhaps, as has been suggested in Parliament, running the NHS should be returned to healthcare professionals.

Or should the public be taking the reins? It is, after all, our tax money that pays for any treatment allocated by the NHS.