Unlike the national lottery, the NHS-prescribing lotto has very little razzmatazz. There is no Saturday night TV show, no holiday of a lifetime up for grabs, and no Dale Winton. The only thing they do have in common is that there are very few winners, chosen at random. But could a 49-year-old nurse from Somerset have changed the NHS overnight? Breast cancer sufferer Barbara Clark's victory this week in her fight to receive the drug Herceptin has prompted speculation that the prescribing process may become a lot less haphazard.
The Herceptin case illustrates perfectly the peculiarites of the current system. Although it has been available on the NHS for use in women with advanced HER2-type breast cancer since March 2002, research by Roche, the pharamaceutical company that makes the drug, showed that a woefully small number of eligible women were being prescribed it. What's more, the decision seemed to be based more on geographical location than clinical need. While 61% of eligible women in the south-east were being treated with Herceptin, only 14% of women in the Midlands and 28% in the north of England were being given a chance to try it.
And that's not all. Earlier this year three large clinical trials suggested that Herceptin might help women with early breast cancer, too, with survival rates up by as much as 50%. Despite this evidence, the drug is not yet licensed for treating early breast cancer. It is currently only available to early breast cancer sufferers whose local primary care trusts agree to fund their treatment; the trusts, and not the centralised NHS, hold the purse strings where drugs are concerned. So again, it's back to postcodes.
Why the geographical discrepancies? Easy: cash. One vial of Herceptin sets the NHS back £407.40. And a 38-week course of therapy (a fairly standard length of treatment) costs a cool £15,500 per patient. While money should be no object if a person's life is at stake, when you compare this to tamoxifen, the current gold standard for post-surgery patients, which costs £2.39 per month, the problem is clear for trusts. With their limited budgets, can the cost of Herceptin be justified?
And it's not just big name drugs that need to be rationed. GPs too have a drug budget for our practice population. Keep within it and we are paid a sweetener by the care trusts (£1.10 per patient in north Bristol, where I practise), but overspend by a single penny and we are penalised by losing the sweetener for the next year.
To help, we are issued with a booklet setting out a traffic-light system for prescribing. Red-light drugs are for hospital prescription only. Amber also need to be started by a specialist, but can be taken over by the family doctor once the dose is stable. Green-light drugs can be prescribed by a humble GP without anyone else's say-so.
But even these aren't always cheap and many are certainly not covered by the current £6.50 prescription charge. So while the health service makes a tidy profit on a course of trimethoprim for cystitis, which only costs £1 for five days' treatment, it loses out on a week's famciclovir for shingles at £123.99. According to the Prescription Pricing Authority, around £8bn is spent annually on drugs, of which only £452m is recouped from prescription charges.
It's not surprising then that practices such mine are allocated pharmacists to audit our prescribing and to carry out the NHS equivalent of a supermarket price check, so they can swap our patients on to cheaper brands of tablets if their tariff drops.
The NHS devours cash. And every time a breakthrough is discovered the situation becomes worse as patients demand new treatments for previously incurable diseases. So while it's thrilling to hear of Barbara Clark's win, that joy is tempered by the knowledge that the payout for her treatment will have to come from somewhere else in the budget. Someone, somewhere will lose out.
Wherever you live healthcare is a lottery and it's rarely a rollover week.
· To ask Simon a question email health@theguardian.com. He cannot enter into correspondence.
