BBC - Health: Who gets what?
Wednesday, October 14, 1998 Published at 11:01 GMT 12:01 UK
By BBC Health Correspondent
Richard Hannaford
Politicians may have difficulty uttering
the word "rationing", but the National
Health Service (NHS) is well aware of what it means and
is getting to grips with its implications.
The debate over the anti-impotence drug Viagra has
forced the government and the public to consider
explicitly whether the NHS can still afford to offer all its
treatments to all of the people.
The Health Secretary will soon announce the restrictions
that will be placed on the release of the little
diamond-shaped pills in the UK. But in truth, Viagra will
be just the latest in a growing list of new drugs to face
such limitations.
Alzheimer's drug
Robert and Julie Breckman are certainly aware of this
new reality after they struggled to get hold of a drug
called Aricept, used to treat Alzheimer's disease. When
it was eventually prescribed for Julie, it helped her
significantly.
"She became more stable," Robert says. "She was able
to start dressing herself. She became more coherent
and it certainly did prove a great benefit to her."
But the improvements eventually went away and Julie
went into a downward spiral. Aricept is one of those
drugs that does not work for everyone - only four out of
10 patients show any improvement at all.
For this reason, some health authorities will not pay for
the drug, while others will only allow it to be prescribed
in clearly defined circumstances.
Special circumstances
Robert and Julie live in the area covered by the
Kensington, Chelsea, and Westminster Health Authority
in London.
It says the drug can only be
prescribed by senior doctors;
should only be given to
patients who have mild to
moderate symptoms; and
that GPs should only
respond to requests by the
patient for Aricept - not
initiate treatment.
It was these conditions that
made it difficult for Julie to
get the drug initially -
especially when her
diagnosis did not fit the
guidance. Robert Breckman believes the decision to
prescribe the drug should be left to the family doctor
alone.
"If the local doctor prescribes a drug, the NHS should
take it up. Otherwise, why employ staff if you're never
going to take any notice of them?"
Careful system
John James, the health authority's chief executive, does
not accept the criticism.
As the person responsible for ensuring the efficient
funding of the NHS locally, he says it is right to set up
guidelines on expensive and unpredictable drugs.
"The difficulty with Aricept and with the other drugs that
are coming in for dementia is that we don't know why
some patients respond and others don't when they have
apparently similar clinical conditions.
"That's why it's right to have a fairly careful system for
ensuring that you continue the drug for those who are
responding and to discontinue it for those who aren't."
Bad feeling
One man's careful system is another's unreasonable
restriction. Dr Sarah Eagger, a specialist in dementia,
accepts the logic of the authority's position, but is
concerned that such restrictions will limit the ability of
doctors to evaluate the real worth of new treatments.
"Doctors have, historically, been used to trying out new
medications and treatments and making their own
decisions about whether a drug works or not and
whether they should continue to prescribe it," she says.
"But it's a brave new world, and I think health authorities,
clinicians and patients really do have to work in
partnership to come up with what is ultimately some
kind of equitable decision-making process where at least
everyone across the country has an equal opportunity to
try something.
"The problem at the moment, especially with this drug,
is that it is very inequitable and that creates a lot of bad
feeling."
Past debate
Some of this ill feeling may disappear when the new
National Institute for Clinical Effectiveness comes into
being next year.
This new NHS body will assess new treatments and
issue guidance on how the health service should
respond to new and expensive drugs.
While the current furore over Viagra has brought
politicians of all colours to the verge of accepting that the
NHS may have to ration, you could argue the Health
Service has already had the debate.
It just wants to know who should have the authority to
decide who gets which drug or what treatment. |
