It's so hard to be nice

Observations on drugs

It cannot be easy to listen to a plea from a man with a disabling and terminal disease and be told, while the nation listens, that you are the reason he will not be helped.

Yet, that was how Andrew Dillon's day started recently, when as chief executive of the National Institute for Health and Clinical Excellence (Nice) he was confronted on the Today programme with the testimony of a man with Alzheimer's disease, shortly after Nice had decided that the National Health Service could not afford the cost of the sufferer's drugs.

It was not the first time that Dillon has been thus vilified. He no doubt expects it. Nice weighs up the economic and clinical case for the NHS paying for new drugs. Limited budgets mean some treatments don't make the cut. But pressure on Dillon is coming not only from those whose health may be affected by his decisions. The drugs companies would rather it was them, and not Nice, who influenced doctors' prescription decisions.

Dillon's organisation is therefore an obstacle. Three pharmaceutical companies are seeking a judicial review of Nice's Alzheimer's decision and have armed themselves with rhetoric that revolves around dying patients and long-suffering carers. They are, of course, the same firms that stand to make millions if the NHS buys their drugs.

It is not the first time that patients have proved useful allies for these firms. Funding patients' groups makes sense, since complaints from sufferers carry enormous emotional weight, especially when a condition as traumatic as Alzheimer's is involved. Yet funding these groups is not necessarily about helping patients. When the Commons Health Select Committee investigated the pharmaceutical industry last year, it concluded that such funding should be considered part of the "relentless and pervasive" promotional efforts of the industry.

It is in the interests of pharmaceutical companies that decisions about what drugs are prescribed rest with doctors and patients. They want to be allowed to advertise to both groups. US deputy health secretary Alex Azar, whose Republican party benefits hugely from pharmaceutical industry donations, made his views on this clear when he lobbied Health Secretary Patricia Hewitt earlier this month.

But a look across the Atlantic at the system Azar helps run tells us precisely why Hewitt must resist his lobbying. The US healthcare system is both unjust and inefficient.

American prescription costs are paid by healthcare insurance. Drug choice then rests with doctors, so pharmaceutical companies woo them with gifts ranging from free pens to conference junkets. Patients can also request specific medicines. Watch evening TV in the States and you face pitches for anything from anti-depressants to treatments for irritable-bowel syndrome.

The result of this free-for-all is that access to drugs depends on the amount you pay in insurance. It also means that drugs companies end up spending billions of dollars on advertising. Some estimates put the total marketing budget of Big Pharma above that of their research spend. Such costs necessarily increase the price of drugs.

So, when Nice's decisions do not make for nice reading, as they often don't, we should bear in mind that it is better for those with emotional and financial interests in a drug to be kept at arm's length from decisions about paying for it. It is a harsh truth for those who suffer from ailments such as Alzheimer's, or those caring for them.

But companies disappointed that they may lose out from Nice's decision must simply be told to stay out of a process about which they cannot be objective. They must, as they already do, be able to make their case to Nice. After that, it has to be up to independent experts to make the tough decisions about how scarce NHS resources can be spent most fairly.

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