Plus ça change: pharmaceutical spending in the NHS
Liz Morrell, Senior Researcher at the Health Economics Research Centre (HERC), Nuffield Department of Population Health (NDPH).
In 1957, the UK National Health Service (NHS) was just nine years old and already grappling with a very familiar problem – the rising cost of prescriptions. The drug bill at the time was £57 million, compared to the £17.4 billion spend in 2017 – clearly a different era. In June 1957, the government tasked the Committee on the Cost of Prescribing, led by Sir Henry Hinchliffe, to investigate, resulting in the Cost of Prescribing (Hinchliffe) report.
On 11 November 2019, the Health Economics Research Centre (HERC) is presenting a symposium to mark the 60th anniversary of the document. The report made a set of landmark recommendations, and the symposium will explore, 60 years on, what has changed. Do we face similar challenges today? What long-term recommendations to address the current challenges could be made by the government?
Many of the recommendations in the Hinchliffe report related to the generation, interpretation, and use of evidence on drug efficacy. These included recommendations on medical training, to include education on economical prescribing, and training to enable doctors to evaluate manufacturers’ claims for their drugs. The report accepts the importance of pharmaceutical industry investment in research and development, but wishes to curb “extravagant sales propaganda, some of which is undesirable”! Further, the report argues for establishment of a permanent expert body “to include men with business experience, an economist and a statistician” to advise on drug costs – presumably women were not invited to apply to be part of this forerunner of NICE?
As a member of the organising group for the symposium, I wanted to find out more about the discussion of the report in parliament, and delved into Hansard, the official record of UK Parliament proceedings. Surprisingly, given the subsequent impact of the report’s ideas, there is little mention of it. The report is mentioned in a debate on prescription charges on 13 July 1959, in which the Minister of Health, Derek Walker-Smith, describes the report as “a factor to be taken into account in the consideration of the relevant circumstances to which I then referred” – hardly a ringing endorsement.
The report then resurfaces two days later, in a speech by Dr Edith Summerskill (Labour), then MP for Warrington. Dr Summerskill spoke for 45 minutes on a range of health issues, suggesting that the government had been dragging its feet in responding to not only the Hinchliffe report, but two others – the Cranbrook report on pregnancy and childbirth, and the Younghusband report on social work. She is rewarded for her efforts by a response from Walker-Smith that begins with an expression of sexism that I hope would now be career limiting, by quoting from Dr Johnson: 'A woman's preaching is like a dog's walking on his hinder legs. It is not done well; but you are surprised to find it done at all.'
It is the breadth of Dr Summerskill’s speech, and not her gender, that deserves further exploration. The first issue she addresses is drug company profits, and their marketing activities, calling to mind the recent US settlements on opioid addiction, and headlines on ‘price gouging’ by the industry. She then moves to the prescription charge, which was introduced in 1952 by the Conservative government despite opposition from Labour. As removing prescription charges was an early act of devolved government in Scotland and Wales, clearly we have still not resolved this issue.
As the speech continues, Dr Summerskill moves to provision of free drugs for private patients; this debate on the somewhat uneasy relationship between private and public healthcare is a forerunner of the ‘top-up’ payments debates of 2008. In the remaining 30 minutes, she proceeds to cover antibiotic resistance, the integration of health and social care, the underfunding of mental health services, improving the safety of maternity care, and air pollution. If it were not for the occasional sexist language, it would be almost impossible to distinguish the debate from today.
Overall, then, the context for the debate on drug costs appears to have changed little in 60 years, so an examination of the Hinchliffe report and its relevance for today is timely. Speakers will come from the NHS, NICE, the Institute for Fiscal Studies, the Office of Health Economics, and the universities of Oxford, York and Bournemouth.
I leave the final words to Dr Summerskill, as she reprimands the Minister of Health for the quality of his response: 'Is the Minister aware that he has not answered one of my questions?'
Perhaps we can do better at the Symposium.
The symposium on the Hinchliffe report takes place on Monday 11 November, at Merton College, 9:30-17:00. Further details and information on registration can be found on the HERC website.