Drugs for the People

(First published in Prospect magazine)

Medicinal drugs are among the most important commodities we
have-our very lives often depend on them. Yet we have less control over whether
we get them, less say in which ones we are allowed, and less knowledge about
them than about almost anything else we consume. In Britain, we are not allowed to see
advertisements for prescription drugs in case we start pestering for them, and
we meekly accept that we may only take what the experts say we should take.

We rationalise this attitude by pointing out the risks associated with
pharmaceutical products. Yet in most cases drugs are less risky than countless
everyday items which we would not dream of restricting. Cars, alcohol and
cigarettes are obvious examples. Nor does the system actually protect us from
adverse drug effects. The real fiascos-antibiotic abuse or tranquilliser
addiction-happen largely because of the way pharmaceutical products are handed
out, not in spite of it.

British consumers have even less control over the drugs they take because, in
addition to laws which prevent us from acquiring many sorts of drugs without a
chitty from the doctor, drug distribution is subject to state control. Nearly
all GPs are employed by the NHS, and almost the entire  six billion-worth of prescription
drugs handed out annually are on NHS prescriptions. Because the recipients do
not pay directly for their drugs, many seem to think they don't pay at all;
this has encouraged the notion that you should be grateful for anything you
get. GPs are not allowed to write private prescriptions during NHS
consultations, and as doctors in private practice are
few, people cannot easily obtain rationed drugs, even if they are happy to pay
the price.

The new policy of clinical governance is now shifting decisions about
drug-taking even further away from the individual. Until recently a doctor
decided whether and what to prescribe, ostensibly on the basis of what seemed
best for the individual patient. Now doctors must prescribe according to
guidelines designed to provide cost-effective care for all on an equitable
basis-a very different thing. The result is that thousands of people are
deprived of drugs which could make their lives better. In many cases they
suffer unnecessarily or even die.

Take the drug Xenical. This ingenious product gobbles
up fat from food in the gut before it can be absorbed. It helps people lose
weight when all else has failed and the worst risk it carries is to produce a
condition delicately known as faecal leakage. Its potential benefits are huge;
its attraction to those who merely want to eat more than they should, yet stay
slim, are obvious. But to get Xenical
in Britain,
you either have to be seriously obese and go through an elaborate series of
diagnostic hoops, or buy the drug through a dodgy slimming clinic which will
charge a large premium.

Then there is Viagra. Viagra can restore sexual function in impotent men, and
may also increase sexual pleasure for normal men because it helps prolong
intercourse. There are some minor risks, but to get Viagra legally in Britain you
have to be diagnosed with a condition which makes Viagra the only means you
have of achieving intercourse. You then get two pills per week.

This system of doling out treatment according to what nanny thinks best was
acceptable when the NHS was set up, because effective drugs were few,
expectations were low, and the principle of equity was unsullied. But it cannot
survive. Designer and "lifestyle" drugs, products which can enhance
normal life as well as relieving illness, are pouring on to the market. Soon we
will be able to mould our bodies and tweak our personalities at will, trading
the slow, painful journey to self-improvement with something popped from a
blister-pack. Medicinal-but-hardly-essential products such as Viagra and Relenza (Glaxo Wellcome's banned flu drug) are the bridge between
old-style medicines and this new type of "lifestyle" pharmaceutical.
Already in development are pills which will boost our memories, control our
appetites and twiddle our genes to slow down ageing. These products will be
seen less as medicine and more as consumer goods-and people are going to want
them, just like they now want designer clothes and mobile phones.

The government seems to think that it can keep the lid on consumer demand by
banning and censoring. But the postwar generation
will not slouch into old age with the stoic acceptance of their parents. They
will fight, like the seasoned consumers they are, for anything which can help
stave off degeneration. Many of the new lifestyle drugs will be designed to
combat ageing and, thanks to the internet, there is no way that the existence
of these products can be kept a secret.

As each new lifestyle drug comes out, we will see the National Institute for
Clinical Excellence struggling to come up with a convincing excuse for banning
it; GPs will become more beleaguered as they are forced to refuse their
patients each new goodie; dubious internet and mail-order sites will flourish;
and eventually British-based pharmaceutical companies-currently responsible for
�5 billion-worth in exports and 60,000 jobs-will pack up and move to
places where they can market their wares more freely.

Yet it doesn't have to be that way. Instead of making it especially hard to get
hold of lifestyle drugs, it could be made especially easy. Such products could
be put on sale (after safety trials, and with full information) without
prescription. A tax could be levied on them, to be earmarked for the NHS. Pharmacists
would be pleased to advise on appropriate use. It would be no more unfair than
allowing (as we do) unrestricted purchase of breast implants or a
collagen-enhanced pout.

You might expect that the argument for de-restriction of drugs would be pursued
most forcefully by the people who make them, but the pharmaceutical industry
has been curiously quiet on the subject to date. One reason is that the
industry's position within the NHS prescribing system is very cosy. Since 1958,
its profits have been effectively guaranteed through an agreement between
government and industry called the Pharmaceutical Price Regulation Scheme
(PPRS). Under this scheme, in exchange for capping prices on NHS drug sales,
the industry is allowed to operate in a way which allows a generous 21 per cent
return on capital invested. Anyway the prescribing system is useful to the
pharmaceutical companies because it provides a ready-made distribution network.

But the system will not work so well for the industry when lifestyle drugs form
a much greater proportion of its output. Unless there are big changes these
products are unlikely to find an easy market in Britain-witness what has
happened to Viagra and Relenza.

Richard Sykes, chairman of Glaxo Wellcome,
was furious when Relenza was banned, and even
threatened to take his company to the US. "Britain can no
longer be seen as... a suitable market for the early launch of new
medicines," he wrote to Tony Blair. "The government has stressed the
need for British companies to invest in research and development... This
judgement will send out the opposite signal."

Sykes's statement was the first public demonstration of industry exasperation.
But more will follow if the government refuses to ease its ban on consumer
advertising. Many new drugs are unavailable in Britain because their makers see no
point in launching them here when they can't advertise them to the people who
want them. Increasing pressure from within the industry, and consumer demand,
will eventually destroy these restrictive practices. The longer the government
fights these moves, however, the more chaotic the collapse will be.

The change, when it comes, will go much further than simply allowing ageing
baby-boomers to reduce their wrinkles or burn off fat without exercising.
Allowing people greater knowledge of, and access to, lifestyle pharmaceuticals
will have a knock-on effect on the use of conventional therapeutic drugs-which
will in turn have a beneficial effect on the nation's health. Britain still
lags dismally behind its European neighbours in many healthcare outcomes.
Survival rates for all types of cancer, for example, are well below the
European average. One reason for this is the slow take-up of new drugs. Under
the present system the average spend per head on drugs
is kept at a low 25p per day-half as much as in France
and Germany.
This is not enough to buy state-of-the-art treatment, and de facto rationing
has operated for years. Given the choice, most people would be willing to pay
more. Most could afford to: the 25p spend is less than a quarter of what we
spend on tobacco and alcohol. Private sale of non-essential drugs would leave
more money available for the NHS to purchase life-saving products and to
prescribe generously to those who cannot afford to pay privately.

More important than these practical benefits is the issue of liberty. Our
bodies are the most personal possessions we have-we have ceded control over
them because in illness we regress, and long for some strong parental figure to
kiss us better. Over centuries we have encouraged the medical profession to
take that role, and have thus colluded in creating a paternalistic system in
which we do not even have the right to know about what we consume. But it is
time to take responsibility for our own health. It is time, in short, to grow
up