Guest comment by David Taylor, UCL Emeritus Professor of Pharmaceutical and Public Health Policy
At the end of September The Times ran an opinion piece called 'Stop the NHS runaway train before it is too late'. In it a journalist called Ross Clark claimed that 'prescribing drugs is far too built in to the culture of the NHS'. He implied that problems such as antibiotic resistance are due to the lax prescribing habits of GPs and that NHS access to low cost generic medicines is now under threat in ways that could soon fatally undermine the funding of the health service.
This was followed up a day later by a letter from my respected friend Ashok Soni, the President of the Royal Pharmaceutical Society. He appeared to support the view that NHS medicines use is a train crash in the making. Ash commented 'not only are many older people taking too many medicines, but they are also not taking them as prescribed.' He quoted work of mine about avoidable medicines wastage costing the NHS £150 million a year, and argued that to remedy this 'every older person should have a regular review of their medicines with a pharmacist to weed out unnecessary treatments'.
Clark is a free market libertarian with no record as a medical journalist. However, his Times contribution undoubtedly reflected popular concerns, especially in the wake of recent attempts to increase the price of an old Burroughs Wellcome drug called Daraprim (pyrimethamine, which was originally marketed as an anti-malarial but has long been used to treat toxoplasmosis) in the US by a swingeing 5,000 per cent.
Some may believe that ill-informed comment about the NHS record of medicines use and the value of the research based pharmaceutical industry in this country is best left unanswered. But unchallenged prejudice can act as a cumulative toxin. Not long ago a former Conservative Minister asked me 'where did we go wrong – why is everything connected with pharmacy from the productivity of medicines research to the NHS' use of drugs such a mess?' When I told him it is in fact an outstanding success he obviously thought I had not been reading the newspapers.
In reality, total NHS spending on pharmaceuticals at manufacturers' prices represents about 10 per cent of all health service costs, or 1 per cent of GDP. This is below the relevant OECD and global means. NHS pharmaceutical outlays have been relatively steady at this proportion for the last half a century, during which time innovative medicines and vaccines have helped to significantly improve UK and global health. For people who like me are aged over 65 they have played a key part in increasing life by some 50 per cent since the NHS was created.
In the case of antibiotic use there is evidence that British GP – and hospital – prescribing ranks as amongst the most prudent in the world, and it would anyway be wrong to suggest that NHS community drug use is the main source of resistance related challenges. The most significant causes of such problems in this country stem from the intensive treatment of immuno-suppressed and other severely ill inpatients.
The available evidence shows that the NHS is a notably careful – some say a too careful – user of new products such as anticancer drugs. No responsible commentator wants to promote excessive medicines use by older people or any other patient group. But there is compelling reason to believe that even mature medicines such as, for example, blood pressuring lowering products are still significantly under-used in this country. The research Ash Soni quoted in his Times letter indicated that at least ten times as much value could be gained from enabling medicines to be taken to better effect as might be generated from seeking to cut avoidable wastage.
The prices of generic medicines can of course go up, especially if there is only one producer. But there is no reason to fear that low cost NHS generic medicines supply is under a significant threat in this country. The recent scandal relating to the cost of the 60 year old drug pyrimethamine in the US stems from counter-productive American regulatory requirements which do not apply elsewhere. Medicines that were on the US market before 1962 were 'grandfathered' after legislation which increased safety testing requirements. They were allowed to remain on sale, but any generic copies would have to be tested like new drugs before they could compete with the original brand.
This historical anomaly in effect gave some products perpetual regulatory data protection in the US. Yet in the UK GSK still supplies pyrimethamine for about £13 for 30 tablets. In countries like India and Brazil it is even less expensive.
Britain would be less able to fund the NHS if it were in future to lose successful life science research based industry. Innovative medicines are in the long term highly cost effective because once the intellectual property rights needed to facilitate research investments expire they can almost always be made universally available at much reduced costs for unlimited periods. By contrast, labour intensive forms of care are likely to stay at roughly the same 'real' cost relative to national wealth for as long as they are in use.
While the average NHS prescription medicine now costs under £10 a month to supply, the price of employing professionals such as pharmacists is normally well over £20 an hour. Community pharmacy services cost the NHS in the order of £3 billion a year, net of the costs of the drugs supplied.
This not to say that pharmacists cannot make themselves worth the money taxpayers spend on them. But as dispensing becomes more mechanised and GPs' and other NHS doctors' prescribing is even better informed by computer based support systems, pharmacy will not be able to justify its costs simply by seeking to cut drug wastage. The way forward is via making sure that all NHS patients have access to the medicines and other health care most likely to result in the best possible outcomes for each individual, and through offering demonstrably effective support to people who might not otherwise be able to take their medicines effectively.