The Maynard Doctrine: Suckling the NHS ‘piglets’ - the case of the drug dealers

The NHS is like a large sow with many teats, from which provider piglets draw succour. One of the most robust piglets in the sty is the pharmaceutical industry.

Take, for instance, the current debate about 'co-payments' for cancer patients. With NICE declining some products of marginal cost-effectiveness, industry is encouraging its compatriots in the medical profession and elsewhere to demand that where patients buy treatments declined by NICE, the administration of the drugs should be provided by the NHS.

If the industry was more modest in its pricing choices, some of these marginal products might be approved by NICE. Sadly NICE cannot negotiate the prices of drugs – yet - and so the pharmaceutical pig is campaigning for more nourishment for its staff and share owners with the co-payment debate.

This neat policy argument diverts attention from pharmaceutical pricing. If the industry was more modest in its pricing choices, some of these marginal products might be approved by NICE. Sadly NICE cannot negotiate the prices of drugs – yet - and so the pharmaceutical pig is campaigning for more nourishment for its staff and share owners with the co-payment debate.

A crucial issue in this debate is opportunity cost. If the NHS looks after patients who have paid for their drugs privately, will this consume capacity which would otherwise have been available for NHS patients? Or will NHS managers use the co-payments to maintain capacity for NHS patients? The latter is the ideal outcome, and may impose minimal opportunity costs on NHS patients.

If, however, local managers use the co-payment revenue on other types of care, then these additional patients with privately funded drugs may crowd out NHS patients.

A ubiquitous problem with this greedy piglet is its relationship to another piglet, the medical profession. These piglets have a nice symbitotic relationship, in which they support each other’s efforts to draw succour from the NHS sow.

The relationship starts at birth. If you meet a first-year medical student, they will have pens and other jollies advertising drugs within a few weeks of their induction into the medical tribe. There is some pressure to have 'drug-free' medical schools, in which 'big pharma' is not allowed to sponsor social events, let alone teaching and education. Sadly, this has not yet happened.

Once qualified, hospital consultants in particular trek to the beaches in summer and the ski slopes in winter. Their destinations are worldwide, and of course all this activity is sponsored by industry and is allegedly “educational” and “scientific”. The fact that research shows that these weary travelers then go home and seek to introduce to hospital formularies the very products marketed to them over their champagne is coincidental! This translation of evidence into practice is fine if the products are demonstrably clinically effective and cost-effective. Sadly this is often not the case, and doctors are being used as marketing devices by the drug piglets.

The medical piglets can grow fat on recycled succour from the NHS sow. Industry makes high profits to fund both marketing to enhance the air miles of medical piglets and innovative R&D to produce the next generation of wonder drugs.

Sadly the essential pipeline of new innovative products for patients has dried up and big pharma is currently seeing its patents expire and no new cost-effective products replacing then in the cash generation system. Such problems enhance the potential rewards from their cuddling up to the medical piglets.

The threat to the flow of nutrients to the industry and its medical supporters requires investment in marketing to propel products of marginal cost effectiveness into the NHS food chain. Sadly for the industry, such wheezes are now subject to NICE scrutiny via NICE and they (like the Scottish equivalent (the Scottish Medicines Consortium (SMC)) are increasingly, and quite rightly, saying no.

The role of NICE and the SMC is to protect the NHS sow. What is taken by the pharma piglet is not available to fund care provided by other piglets. They, like all other piglets, have to be disciplined and educated into the primacy of the role of cost-effectiveness in prioritising the allocation of the sow’s goodies!