Tablet of stories reveals an unhealthy obsession with drugs – Health Policy Today, 19th August 2008
In today's press there are 17 pieces relevant to the ongoing debate about access to drugs; their cost; and how we judge their effectiveness. There are also reports of safety concerns, but by far the biggest volume of stories (7 from 15) relate to potential new discoveries. This tablet of stories reveals an unhealthy social obsession with drugs.
Listing all these stories in a table allows them to be moved around, better revealing the contours of our drugs debate (pasted at the foot of this piece).
There are six themes (1) stories about access to drugs, (2) access to drugs, (3) changes to clinical management – screening, new treatments, (4) questioning the evidence behind certain treatments, (5) reports of safety concerns, and (6) the largest number, on potential discoveries that could be translated to new treatments.
A. STORIES ON ACCESS TO DRUGS
Today’s Oxford Mail reports that a group of campaigners in Oxfordshire are lobbying to overturn NICE’s draft guidelines on Sunitinib (one of the drugs for advanced-stage kidney cancer). They are also trying to get Oxfordshire PCTs to finance the drug in advance of the ruling. It may be a sign of things to come. As PCTs make funding decisions, and rule of exceptional cases, we may see more local campaigns, unless the NHS constitution moves to make PCT rules more uniform.
Those who only glanced at the Mail headline - Nurses threaten court action if NICE restricts £100-a-week arthritis drugs - would have wrongly assumed that a group of nurses are threatening court action if NICE restricts a particular drug for arthritis. This is just a test. The Daily Mail likes to keep its readers on their toes and the text of the article doesn’t mention the word ‘nurse’ or ‘arthritis’ once. Instead it is a summary of the arguments presented in last night's BBC Panorama programme – ‘The NHS postcode lottery: it could be you’, which was heavily critical of the postcode lottery in the availability of drugs.
For a summary of the programme – see yesterday’s HPT – 'A panoramic debate widens further still'. (www.healthpolicyinsight.com/?q=node/151) For an ill-tempered review, featuring words of four letters and more, read the second part of Andy Cowper’s blog written just after he saw the programme, 'Money for nothing for the Ritalin generation' (www.healthpolicyinsight.com/?q=node/152). Those easily offended by profanity should instead read his discussion of the NICE defence before he saw the show, 'Rawlins and Dillon show attack is the best form of defence' (www.healthpolicyinsight.com/?q=node/150) ...
B. STORIES ON THE COSTS OF DRUGS
The Mail article describes Michael Rawlins ‘attack’ on the pharmaceutical firms’ pricing of drugs as ‘an astonishing attempt to shift the spotlight’. A piece in the Telegraph completely agrees: ‘It is the sort of argument you expect from a sixth-form debating society - not a former professor of clinical pharmacology’.
Margaret McCartney, the Glasgow GP and regular FT columnist defends the NICE chairman. ‘I think he’s absolutely right’. She offers a very straightforward view. ‘If NICE decides an intervention is not cost-effective then the intervention needs either to be made better, or cheaper, in order to compel us to prescribe it.‘
She continues, ‘the problem is that rationing healthcare interventions is inevitable. Even if we (rightly) save money by stopping inappropriate prescribing and other ineffective interventions, there are still going to be limits and hard judgment calls to make. These decisions should be made openly and as fairly as possible.
In the Scotsman, GP John Garner says that drug firms can use ‘clever pricing strategies’ to gain a foothold in the healthcare market, and suggests that the cost effectiveness should be reviewed if costs change. Not all proposals to save money, he says, end up making savings.
‘Another proposal likely to cause doctors considerable work in explaining the rationale for change to patients is one regarding cancer. There are a number of equally effective drugs available in the treatment of prostate cancer, and most patients are on a drug that is inserted every three months as a pellet into the tummy wall. This costs £267.48 every three months. Another similar drug costs only £207 but is a liquid and has to be injected into the patient's bottom. While both drugs are equally efficacious, it will require a considerable amount of explanation to reassure patients that the change will make no difference to their treatment. I question whether the additional time, effort and anxiety justifies the £20-a-month saving. The cynic in me also wonders whether, once a large chunk of the market is captured by the new firm, if the price will remain the same for long.’
The Independent today has a feature on ‘the big question: ‘are drug companies ripping off the National Health Service?’ So after the flow of argument, who is right?
‘Both sides. Drug companies do need strong profits to invest in research and development. But their marketing budgets now dwarf spending on R&D. And some 80 per cent of their R&D innovation is directed at developing profitable medicines that offer no real therapeutic advance. Drug companies offer myriad products with different combinations of the three main analgesics – aspirin, paracetamol and ibuprofen – all of which are available at a fifth of the price in their generic forms. Some medications add caffeine to "enhance the analgesic effect", though you could get the same effect with a paracetamol and a cup of tea. We are, increasingly, a drug-taking culture.’
C. REPORTS OF CHANGES TO CLINICAL MANAGEMENT
Both the Times and the Guardian report that NICE is expected next week to approve the screening of ten-year-olds for a rare genetic condition that causes very high cholesterol levels. The Times says, ‘Carriers run the risk of developing heart disease at a much younger age than other people, and dying from it before they are aware of the risk.’
‘The tests aim to detect familial hypercholesterolaemia (FH), the commonest genetic disorder among people of European descent’.’‘The Netherlands has introduced such a scheme, with great success. NICE is understood to have concluded that cascade screening would be straightforward to introduce in Britain, would cost relatively little, and could save thousands of lives.
‘In the US, children as young as 8 who suffer the condition are given statins. In Britain, Dr Rees said, there was no consensus over the age at which treatment should start, but clinical trials in patients from the age of 8 in the Netherlands had shown no ill-effects. The problem remains unrecognised by many GPs, he said. One of his patients, now 21, has been on statins since she was 14. She came off them to have a baby, which was born absolutely normally. When, after moving house, she went to her new GP for a fresh statin prescription, she was told that it was unthinkable to give statins to someone so young.’
One of the good things about modern media is that people leave comments. Jane from Bognor Regis worries whether we should be putting young children on statins, which have side-effects including muscle, kidney and liver damage.
A week earlier, Glasgow GP, Margaret McCartney began her column by saying, soon we will have to ask who isn’t on statins rather than who is. She worries that we are medicalising the problem.
D. QUESTIONING EVIDENCE ON TREATMENT GUIDELINES
Amongst the opinions expressed on drugs is a reminder that the evidence is often contested.
The following text is an edited version of a letter from Nigel Dudley, a consultant in stroke medicine, that was published in the BMJ on Friday. He questions the information provided to the media ‘from the press conference at which the National Institute for Health and Clinical Excellence (NICE) and the Royal College of Physicians released their joint press statement on their stroke guidelines.1 ‘
‘The first line was: "Approx 4,500 people could be prevented from being disabled through stroke if they were thrombolysed." This figure is unbelievable, given the Department of Health’s estimate of a 13.1% absolute benefit of recovery to independence (131 per 1,000 treated) as it means that some 34 351 patients would have to be given thrombolysis. The Department of Health’s December 2007 impact assessment indicated that 549 would recover to independence, with a range of 307 to 792. The "extra points" from the conference included, "further thousands of lives could be saved if all patients were admitted directly to an acute stroke unit (but we do not have a specific figure as not all the variables are known)." What is the evidence for this claim? As Barer points out2 90% or more of patients with stroke will be ineligible for the treatment. They need good medical and rehabilitation care pathways for their particular needs. The final claim—"We do not need any more resources to fulfil the recommendations, just better organisation of what we have already"—would leave reasonable and informed members of the public, primary care trusts, and politicians rubbing their eyes in disbelief. The Department of Health’s impact assessment document and the costing report that accompanied the NICE stroke guidelines make it very clear that the NHS will require more resources to deliver the recommendations.’
The letter concludes, ‘such claims, which then escape into the public domain via newspaper reports and online publications, need justification and clarification lest they undermine the credibility and authority of the guidelines.’
E. REPORTING SAFETY CONCERNS
Obviously reflecting editorial policy, the Daily Mail headline, ‘How doctors are turning millions of us INTO addicts’ is somewhat alarmist and inaccurate. It turns out that this is not the work of a rogue medical group hoping to profit from its cunning plan. It is more serious, to do with the addictive qualities of certain pharmaceuticals and their dangerous side-effects.
The paper reports that ‘more than 600 people now suing the pharmaceutical company GlaxoSmithKline for damages on the grounds that they were not warned of the possible side-effects, such as personality changes, as well as addiction. 'The doctor told me it was not addictive and that's what it said on the information sheet,' says Gina, who lives near Morecambe in Lancashire.’
That particular example related to Seroxat, but there are a range of other drugs to which people are legally addicted. ‘It is thought that between three and seven million Britons are affected, with antidepressants, tranquillisers, sleeping pills and pain-killers the main culprits.’
‘'We took these medicines in good faith,' says Barry Haslam, who was addicted to benzodiazepine for ten years after being prescribed it for work-related stress and anxiety. 'No one ever warned about what might happen,' he says. He now runs the Rock Street Resource Centre in Oldham, one of a handful in the country that supports people addicted to prescription drugs. The number of affected patients in Oldham alone is reckoned to be 5,000. Yet Haslam receives only enough funding for one full-time and one part-time counsellor to visit GPs' surgeries to offer help.
F. THE GREATEST VOLUME OF STORIES IS ON POTENTIAL DISCOVERIES
What is really interesting, though, in analysing the day’s press is that the majority of stories are dedicated to potential treatments and new discoveries. These range from ‘chewing gum helps recovery from bowel cancer surgery' (is it to be issued on the NHS? If the patient prefers 45p Orbit to 35p Wrigleys, will the patient be allowed to co-pay?), through to new impants, light therapy and potential drugs.
My personal favourite of the potential discoveries was reported on the 1st of August. It is a pill that gets you fit without exercise.
Our appetite for drugs is seemingly insatiable, and health stories appear to be a drug of their own, to which we are addicted.
A TABLE OF DRUGS RELATED STORIES - Tuesday, August 19, 2008
A ACCESS TO DRUGS
1 "Authority 'on back foot' over cancer treatment" Oxford Mail
2 "Nurses threaten court action if NICE restricts £100-a-week arthritis drugs". Daily Mail
B COST OF DRUGS
3 Nice not easy Financial Times – regular column by GP Margaret McCartney
4 "Bashing drug companies is Nice work if you can get it" Daily Telegraph
5 "The Big Question: Are drug companies ripping off the NHS?" The Independent
6 "Don't forget, some drugs save lives – and money" Scotsman – GP John Garner
C CHANGING CLINICAL MANAGEMENT
7 "Families to get cholesterol tests" BBC News Online
D QUESTIONING EVIDENCE
8 "Are NICE stroke guidelines scientific or political?"
Letter to the BMJ questioning the evidence behind stroke guidelines
E SAFETY CONCERNS
9 How doctors are turning millions of us INTO addicts Daily Mail on the addictive effects of anti-depressants, still widely prescribed
10 "European court backs ban on Red Bull over health concerns" Belfast Telegraph
F POTENTIAL DISCOVERIES
11 "Treatment advance for drug-resistant diseases" The Independent
12 "Could vitamin C jabs cure cancer? Daily Mail
13 "The 'scaffolding' breakthrough that rebuilds skin' Daily Mail
14 "I limped for 10 years - but a tiny implant cured it in seconds" Daily Mail
15 "Poor weather this summer could trigger increase in depression" Scotsman
16 "Eye opening discovery may lead to new drugs to regulate sleep" Daily Telegraph
17 "Chewing gum aids bowel recovery BBC News Online