As part of its plans for reforming the NHS in England, the government is looking at how our medicines are selected and what they cost. This may sound like a remote and technical question. But it has been a prominent and controversial issue in our long debate about what kind of health care the state can really offer – and afford.
The creation and selling of medicines was well established before the creation of the NHS. Doctors knew that patients expected medicines as a kind of symbolic proof of adequate care – whether the medicine was clinically essential or not.
So when the NHS arrived in the late 1940s – initially offering free prescription – long queues formed, and the government began to panic. Dr Martin Gorsky of the London School of Hygiene and Tropical Medicine notes that civil servants failed completely to anticipate “pent up demand”.
Health minister Aneurin Bevan knew the scale of need, but saw excess too. “I shudder to think,” he wrote in 1949, “of the ceaseless cascade of medicine which is pouring down British throats at the present time. I wish I could believe that its efficacy was equal to the credulity with which it is swallowed.” The Treasury swiftly demanded the introduction of prescription charges, and began its own campaign to rein in medical spending.
Such disputes highlighted the most sensitive issue in British health care: rationing. In theory, the NHS provided for limitless care based solely on clinical need. In practice, various forms of rationing, some more overt than others, have always applied. Deciding who received which medicine became a fascinating battleground between government, doctors, patients and pharmaceutical companies.
Development of new medicines and treatments added to the pressures. Antibiotics, pioneered in the 1940s, were publicised as a miraculous new cure. Their increased use for more trivial conditions was driven not only by medical enthusiasm but also by impatient patients. Minor illnesses, it was assumed, were no longer something you simply had to endure until nature made it better. In mental health, too, the move since the late 1950s from confining patients in asylums to ‘care in the community’ was, Dr Gorsky points out, accompanied by a more extensive use of drugs.
So the NHS bill for expenditure on medicines rose relentlessly, aided by pharmaceutical companies’ skill in marketing products and influencing the medical profession. Companies insisted that their profits were essential to fund research on new medicines and sustain an industry providing Britain with skilled scientific jobs.
Governments tried from time to time to reduce the cost. In the 1950s ministers held talks with the industry over ‘fair’ levels of profit; in the 1960s restrictions were placed on promotional spending. And in the 1980s, a list of cheaper generic products was announced, to be substituted in NHS provision for more expensive branded drugs.
Underlying all this was an attempt to decide where the NHS’s limited resources were best spent, seeking what Gorsky calls “a scientific method of assessing cost-effectiveness”. The National Institute for Health and Clinical Excellence (NICE) was created with the task of measuring what treatments deliver in terms of effects on a patient’s life.
This has introduced a new element into the debate but has hardly silenced the clamour. Doctors resist what they see as interference with their clinical judgement. The media avidly covers claims that patients are denied crucial new treatments. And the pharmaceutical industry protests that its future will be undermined if the NHS spends too little on its products.
So the challenge of health service spending remains. Despite cherished beliefs that care is free and unlimited for all, resources are, in the end, limited. “One person’s hip replacement can mean the loss of someone’s palliative care,” as Gorsky says. That kind of trade-off may not always be so visible. But the pills we are – or are not – prescribed make brutally clear what, for all its promises, the NHS can really provide.
Chris Bowlby is a presenter on BBC radio, specialising in history. This series is produced with History & Policy. You can find out more about them and read their papers at www.historyandpolicy.org