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london A new rationing debate begins in the UK
THE LANCET
DISPATCHES
LONDON
A new rationing debate begins in the UK
T
he dreaded “R” word returned to newspaper front pages last week: a Labour government plan that could ration costly drugs. In a kiteflying exercise, ministers leaked to the Daily Telegraph various options for controlling drug expenditure that the government’s review of healthservice spending was examining. The Conservative-leaning newspaper noted that a decision to establish a national list of approved drugs “would be a fundamental break with the previous Government’s policy that there should not be a blanket ban on treatments”. But the newspaper also acknowledged that the current system had produced “postcode prescribing”— leaving local health authorities to decide prescribing priorities meant access to expensive drugs was now dependent on where a patient lived. For cancer, HIV, multiple sclerosis, and other illnesses requiring medicines which could cost more than £10 000 a year, moving house to obtain free prescriptions was becoming a serious option for patients. The Royal College of Physicians among others has urged ministers to be more open and rational about rationing: an overt rather than covert system which several nations—New Zealand, the Netherlands, Norway— have already introduced. Alan Langlands, the NHS chief executive, told a British Medical Association conference last week that ministers would need to address rationing even though all governments were keen to avoid the use of
STRASBOURG
the word. He went on: “It is no good in the real world for the NHS Executive or the medical colleges pumping out standards and protocols if we leave the people in the system to make up their minds what is important.” What happened at local and national level would have to be sorted out in the forthcoming White (policy)
“The impetus behind the new moves is a steadily rising NHS drugs bill” Paper on the NHS which is expected in December. Tessa Jowell, the public-health minister, spoke to a fringe meeting at the Labour Party conference earlier this month organised by three key medical pressure groups in HIV, Alzheimer’s disease, and multiple sclerosis. Where expensive new drugs were introduced, ministers had to ensure the former treatment services that were made redundant should be phased out, she said.They also had to ensure that the long-term effects were beneficial. This required clear evidence on the effectiveness of drugs and a new balance between drug expenditure and hospital provision. This would require wide consultation. “Getting it right is difficult when we do not know the long-term benefits of new treatments. Although the first generation of a new drug may not be effective, succeeding generations could be.” The impetus behind the new moves is a steadily rising NHS drugs
bill—up from 10% of the NHS budget in 1991 to 14% last year. The NHS is now spending £6 billion on drugs. The annual number of prescriptions in the past decade has risen from 400 million to 600 million and the number per head from 7 to 10·5. Some drugs have achieved major savings. But even the industry now concedes another reason for the high drugs bill is overprescribing. A report from the Audit Commission, an independent monitor of government spending, suggested 3 years ago that overprescribing was wasting £245 million a year. One option that the industry is pushing is to increase the list of drugs which pharmacists can sell over the counter. The industry is already circulating family doctors with a list of 1000 drugs which are cheaper to buy over the counter than on a prescriptions. But encouraging OTC sales is unlikely to reduce overprescribing. Already seven out of ten patients who visit a general practitioner leave with a prescription. Langlands put forward another option. Currently, the NHS absorbs 5·8% of the UK’s gross domestic product and 13·8% of public expenditure. If spending could be ratcheted up to 6·3% and 14·8%, respectively, no rationing would be needed. This could be achieved if health spending was increased by 3% a year in real terms for a decade—a target which the last Conservative government achieved. Malcolm Dean
Will Europe’s forthcoming single currency bring health benefits?
P
roposals for composition of “Euro” coinage suggest a proprietary nickel-free alloy for small-denomination coins on health grounds: the need to avoid nickel sensitisation is already the subject of a 1994 European Union Directive on jewellery. Only high-value 1 and 2 Euro coins will include nickel. They will incorporate anti-forgery precautions by means of two colours and three layers of alloys, currently difficult to achieve with available nickel alternatives. These will represent only 8% of the coins in circulation, says the Commission. However, the proposal is contested by David Hallam, a Labour
Vol 350 • November 1, 1997
member of the European Parliament whose UK constituency happens to include a nickelproduction plant. He cites a Commission response to a parliamentary question in September, where the EU Scientific Committee for Toxicity and Ecotoxicity of Chemical Compounds had opined that “there was no evidence to suggest that current coinage had been associated with the initiation of sensitisation”. As for those already sensitised, the Committee concluded that “very few cases of dermatitis may be caused by the release of nickel from presentday coins, both in the average consumer and in workers profes-
sionally handling coins”. Further studies seemed necessary to obtain “statistically significant evidence concerning the eventual role of nickel release from coins in relation to aggravation of hand eczema”. Hallam describes the coinage proposals as “nonsense based on anecdote and prejudice”, while the Swedish company holding the rights to the more expensive nickel-free Nordic Gold “will do very well”. The Parliament voted on Oct 21 to reject a plea from EU ministers to handle the “Euro” proposals under fast-track procedures. Arthur Rogers
1305
DISPATCHES
LONDON
A new rationing debate begins in the UK
T
he dreaded “R” word returned to newspaper front pages last week: a Labour government plan that could ration costly drugs. In a kiteflying exercise, ministers leaked to the Daily Telegraph various options for controlling drug expenditure that the government’s review of healthservice spending was examining. The Conservative-leaning newspaper noted that a decision to establish a national list of approved drugs “would be a fundamental break with the previous Government’s policy that there should not be a blanket ban on treatments”. But the newspaper also acknowledged that the current system had produced “postcode prescribing”— leaving local health authorities to decide prescribing priorities meant access to expensive drugs was now dependent on where a patient lived. For cancer, HIV, multiple sclerosis, and other illnesses requiring medicines which could cost more than £10 000 a year, moving house to obtain free prescriptions was becoming a serious option for patients. The Royal College of Physicians among others has urged ministers to be more open and rational about rationing: an overt rather than covert system which several nations—New Zealand, the Netherlands, Norway— have already introduced. Alan Langlands, the NHS chief executive, told a British Medical Association conference last week that ministers would need to address rationing even though all governments were keen to avoid the use of
STRASBOURG
the word. He went on: “It is no good in the real world for the NHS Executive or the medical colleges pumping out standards and protocols if we leave the people in the system to make up their minds what is important.” What happened at local and national level would have to be sorted out in the forthcoming White (policy)
“The impetus behind the new moves is a steadily rising NHS drugs bill” Paper on the NHS which is expected in December. Tessa Jowell, the public-health minister, spoke to a fringe meeting at the Labour Party conference earlier this month organised by three key medical pressure groups in HIV, Alzheimer’s disease, and multiple sclerosis. Where expensive new drugs were introduced, ministers had to ensure the former treatment services that were made redundant should be phased out, she said.They also had to ensure that the long-term effects were beneficial. This required clear evidence on the effectiveness of drugs and a new balance between drug expenditure and hospital provision. This would require wide consultation. “Getting it right is difficult when we do not know the long-term benefits of new treatments. Although the first generation of a new drug may not be effective, succeeding generations could be.” The impetus behind the new moves is a steadily rising NHS drugs
bill—up from 10% of the NHS budget in 1991 to 14% last year. The NHS is now spending £6 billion on drugs. The annual number of prescriptions in the past decade has risen from 400 million to 600 million and the number per head from 7 to 10·5. Some drugs have achieved major savings. But even the industry now concedes another reason for the high drugs bill is overprescribing. A report from the Audit Commission, an independent monitor of government spending, suggested 3 years ago that overprescribing was wasting £245 million a year. One option that the industry is pushing is to increase the list of drugs which pharmacists can sell over the counter. The industry is already circulating family doctors with a list of 1000 drugs which are cheaper to buy over the counter than on a prescriptions. But encouraging OTC sales is unlikely to reduce overprescribing. Already seven out of ten patients who visit a general practitioner leave with a prescription. Langlands put forward another option. Currently, the NHS absorbs 5·8% of the UK’s gross domestic product and 13·8% of public expenditure. If spending could be ratcheted up to 6·3% and 14·8%, respectively, no rationing would be needed. This could be achieved if health spending was increased by 3% a year in real terms for a decade—a target which the last Conservative government achieved. Malcolm Dean
Will Europe’s forthcoming single currency bring health benefits?
P
roposals for composition of “Euro” coinage suggest a proprietary nickel-free alloy for small-denomination coins on health grounds: the need to avoid nickel sensitisation is already the subject of a 1994 European Union Directive on jewellery. Only high-value 1 and 2 Euro coins will include nickel. They will incorporate anti-forgery precautions by means of two colours and three layers of alloys, currently difficult to achieve with available nickel alternatives. These will represent only 8% of the coins in circulation, says the Commission. However, the proposal is contested by David Hallam, a Labour
Vol 350 • November 1, 1997
member of the European Parliament whose UK constituency happens to include a nickelproduction plant. He cites a Commission response to a parliamentary question in September, where the EU Scientific Committee for Toxicity and Ecotoxicity of Chemical Compounds had opined that “there was no evidence to suggest that current coinage had been associated with the initiation of sensitisation”. As for those already sensitised, the Committee concluded that “very few cases of dermatitis may be caused by the release of nickel from presentday coins, both in the average consumer and in workers profes-
sionally handling coins”. Further studies seemed necessary to obtain “statistically significant evidence concerning the eventual role of nickel release from coins in relation to aggravation of hand eczema”. Hallam describes the coinage proposals as “nonsense based on anecdote and prejudice”, while the Swedish company holding the rights to the more expensive nickel-free Nordic Gold “will do very well”. The Parliament voted on Oct 21 to reject a plea from EU ministers to handle the “Euro” proposals under fast-track procedures. Arthur Rogers
1305