The seventieth anniversary of the NHS has made me reflect on how proud I am to have contributed to its work for over the past twenty-odd years. Founded on 5 July 1948, the service continues to this day to operate to the same three core principles – meeting the needs of everyone, free at the point of delivery, and based on clinical need.
Aside from providing comprehensive, high-quality healthcare services to virtually the entire UK population, the other thing that the NHS is known for is the constant political bickering that carries on in the background, with criticisms about chronic under-funding and stealth privatisation. However, these are not new issues, with medicines an important reason for the challenges the NHS now faces.
In a response to concerns about rising costs, perhaps the first controversial reform to the NHS was the introduction of a one-shilling charge for prescriptions by the Churchill government in 1952. Despite a temporary abolition in the 1960s, these charges persist today (at least in England) at a cost of £8.80 per item, raising over half-a-billion pounds each year. A substantial proportion of the population are exempt, including children and older people, but charges have nonetheless been claimed to be an important barrier to many patients accessing effective treatment.
Another key challenge the NHS faces is the introduction of new medicines. The vast majority of modern drugs were not available when the NHS was founded. Of the medications most widely dispensed in the community, the top three – statins, proton pump inhibitors and ACE inhibitors – were only introduced in the 1980s.
Robust evaluations by the National Institute for Health and Care Excellence (NICE) are carried out to ensure that new therapies are cost-effective. These have helped considerably to reduce postcode prescribing and to ensure that NHS expenditure on pharmaceuticals represents value for money. However, controversial decisions have been taken, with refusals to fund expensive but clinically effective treatments. Yet costs continue to spiral upwards: primary care expenditure on the blood-thinning drugs rivaroxaban and apixaban, both of which have been approved for barely more than five years in the UK, was over £300 million in 2017.
And finally, there is our enthusiasm for prescribing in the first place. Dispensing of prescription medicines has more than doubled in the past twenty years, driven by increasing levels of multimorbidity, an ageing population, and a plethora of single-condition evidence-based clinical guidelines that fail to consider the potential adverse consequences of polypharmacy. The cost of medicines to the NHS is now at least £15 billion per annum.
Dealing with these pressures is difficult and, ultimately, more funding is required to support the delivery of modern pharmaceutical interventions. Strategies suggested for saving money on medications include restricting ’low-value’ treatments and those where over-the-counter alternatives are readily available. Robust cost-effectiveness studies by NICE are invaluable for informing decision making. The role of the pharmacist is changing, with practice-based pharmacists working closely with GPs and providing clinical services to support rational use of medicines beyond simply dispensing of prescriptions. And the introduction of national guidance on multimorbidity and polypharmacy may also do something to stay the growth of prescribing.
My own research group is particularly interested in this topic: we are currently looking at ways of improving how we can measure polypharmacy to help identify those patients who would benefit most from medication optimisation, and our recently funded IMPPP clinical trial will test a general practice based pharmacist intervention to improve care for patients prescribed multiple medications.
Medicines are one of the fundamental therapeutic options available to clinicians and have revolutionised health and well-being. Solving the challenges that come with their use is essential so that equitable access to treatments is maintained as our NHS enters its eighth decade.
This post is based on an editorial originally published in Prescriber (pp4, July 2018), with permission.