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 whe= ther 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 t= o 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 countl= ess everyday items which we would not dream of restricting. Cars, alcohol and cigarettes are obvious examples. Nor does the system actually protect us fr= om adverse drug effects. The real fiascos-antibiotic abuse or tranquilliser addiction-happen largely because of the way pharmaceutical products are han= ded 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 withou= t a chitty from the doctor, drug distribution is subject to state control. Near= ly all GPs are employed by the NHS, and almost the entire<= span style=3D'mso-spacerun:yes'> six billion-worth of prescr= iption 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 practic= e 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 seem= ed 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 g= obbles 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 hu= ge; its attraction to those who merely want to eat more than they should, yet s= tay 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, a= nd 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 ca= nnot survive. Designer and "lifestyle" drugs, products which can enhan= ce normal life as well as relieving illness, are pouring on to the market. Soo= n we will be able to mould our bodies and tweak our personalities at will, tradi= ng 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" pharmaceutic= al. 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 wa= nt 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 generati= on will not slouch into old age with the stoic acceptance of their parents. Th= ey will fight, like the seasoned consumers they are, for anything which can he= lp 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 existen= ce 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 bann= ing it; GPs will become more beleaguered as they are forced to refuse their patients each new goodie; dubious internet and mail-order sites will flouri= sh; 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 co= uld 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. P= harmacists would be pleased to advise on appropriate use. It would be no more unfair t= han 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 pur= sued 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 1= 958, 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 netw= ork.

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 exasperati= on. 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 w= ho want them. Increasing pressure from within the industry, and consumer deman= d, will eventually destroy these restrictive practices. The longer the governm= ent 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 pharmaceutic= als will have a knock-on effect on the use of conventional therapeutic drugs-wh= ich 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. Und= er 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 p= ay 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 lea= ve 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 figur= e 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 gr= ow up