Time for a commonsense revolution?

The spat between the government and the pharmaceutical industry over the anti-influenza drug Relenza reveals how fast New Labour wants to centralise control of the NHS and bring policy discussion into the public arena. Drug licensing has always taken place behind closed doors, and negotiations over pricing behind locked and bolted ones. With Relenza the industry had to make its case under media gaze, where its shaky foundation became instantly apparent.

Relenza itself is of only symbolic significance. It could be made available over-the-counter to all who want to buy a few days less illness. The important point is that the story demonstrates that the NHS is selective, not comprehensive. Citizens are entitled only to immunisation against influenza, not to treatment. Limited or shrinking entitlement is not new. Plastic surgery ‘on the NHS’ has long been rationed to those with injuries requiring reconstruction, and not made available to the vain, ostensibly because there are too few plastic surgeons, as if this shortage was not deliberately created and maintained. Infertility treatments are available at public expense only to those deemed deserving by health authorities, usually by back-door deployment of guidance with no legal standing. But after Relenza ‘no’ means ‘no’, unambiguously and publicly.

This is logical, as long as we can accept utilitarian logic. The greatest good for the greatest number is not achieved by spending large sums of money on a drug of uncertain value used to treat an unpleasant but self-limiting illness, especially when that small minority at real risk can be immunised. If, on the other hand, we decide that all lives are of equal worth — the deontological view — then we may slip into the post-modern perception that all problems are of equal significance and all plausible solutions equally meritorious. Those with a sense of deontological entitlement may see the rejection of Relenza as undermining civilised standards in medical care.

Expect, then, the Roundheads and Cavaliers of medicine to square off against each other as the command and control culture of the NHS reasserts it public health and cost-containment agendas. This is likely to have two consequences. Conflicts with the professions over resource allocation will become more public, and more intense. How New Labour handles these conflicts will be crucial for the debate about health care, and the signs so far are not positive. Blair’s attack on conservatism included the British Medical Association, implicitly if not explicitly, provoking fresh professional opposition to the government’s reform plans. Health Minister Milburn’s new focus on cardiologists can be seen as partly an attempt to mollify professional interests, as well as an escape from the quicksand of waiting lists.

Conflicts with consumers will also escalate, perhaps fuelled by pharmaceutical industry funds, as the NHS becomes increasingly selective — and the demand for private provision of both allopathic and alternative therapies will increase. The professions will oblige, as chiropodists, physiotherapists and some medical specialists already have, draining resources from the public sector. GPs may also learn how to do this, especially if changes in primary care lead to the redistribution of resources from the relatively affluent shires to the relatively underfunded cities. All this will happen in public, leaving the government of the day with the need to rationalise the situation, perhaps by changing the funding of the NHS to a continental-style social insurance system for core services and private top-up for those who can afford it.

This explicit two-tier service might be avoidable, if resources were allocated to the NHS on a larger scale than this government dares talk about. Increasing the share of GNP spent on health care to the EC average, from the current 6 per cent to nearer 8 per cent, would take some of the sting out of selectivity, but would mean higher taxes. That kind of commonsense requires a revolution, and there are few signs that one is imminent.