Surely it is time to stop using the incredibly misleading term ‘legal high’ with its safe, non-addictive, not-bad-enough-to-be-banned connotations. It’s a lie. The internet is littered with websites selling untold numbers of chemical compounds, blithely labelled with seductive names and proclaimed as legal, ‘quality research chemicals and herbal incense’, getting away with it through a bold disclaimer of “STRICTLY NOT FOR HUMAN CONSUMPTION”.

To try and start classifying them is financially and logistically possible, even though the All-Party Parliamentary Group for Drug Policy Reform (clue is in the name) calls for the Utopian solution of the an introduction of a new category for psychoactive substances whereby their supply can be ‘regulated’ and a review of the government lead for drugs to ensure a health focus. Yeah right.

The first step from the government surely has to be to a serious focus on deterrence. Insist on accurate labeling such as ‘high risk unclassified highs’ in all commentary – because there is never, ever anyway of the public being sure what is in the psychoactive substance. Possession should automatically incur a significant fine – pills, powder, whatever – you are potentially endangering yours and others lives. It may be herbs and talc but life is too short to test everything – the European Monitoring Centre for Drugs and Drug Addiction identified 73 new substances in 2012 alone - and it sends a message of principle. It is ridiculous that they can have ‘not fit for human consumption’ on the packet as a legal requirement alongside names such as gogaine, spellweaver, charlie and e-scape.

The American example of “analogue” legislation which simply automatically bans any new substance that has a similar chemical structure to an already banned drug is worth considering but it can never keep pace with new products coming to market. There are hundreds if not thousands of labs in Asia where new synthetic drugs are synthesised to imitate the effects of existing legal drugs. We have to keep this simple, and act now, if we are to prevent more tragic episodes of injury and death.

Thanks to #LoveInfographics for this one. Following on from yesterday’s press on Big Tobacco pushing e-cigarettes, this graphic illustrates the impact of the nicotine, although it doesn’t show what side-effects are due to nicotine, and which are due to tobacco smoke.

That said, we can be sure that the $6,000 profit that Big Tobacco makes from each smoker in their lifetime will continue to reward shareholders and contribute to their daily $23 million marketing spend – and that’s just in the US! No wonder so many people are addicted. (Infographic is large so will take time to resolve).

Nicotine replacement therapy (NRT) is already available on the NHS, though research shows that simply prescribing NRT (such as the gum or patches) without any formalised withdrawal programme or psychological support has a measly 5% success rate. There is no indication that Big Tobacco wants anything to do with helping people kick the habit. This is only about exploitation and profits, no altruistic concern with harm reduction.

Should e-cigarettes get approval, the article indicates that it will be down to local commissioners to decide whether they are available in your area. We can be certain that Big Tobacco will be doing what they can to persuade doctors to prescribe. Yet the bigger questions remain. Harm reduction is a controversial approach for any risky behaviour. Critics say that it implies that you can carry on with certain activities in a safer way, when the reality is people take more risks because they think perceive what they are doing to be less harmful. Of course, with e-cigarettes you cut out the health risks of inhaling smoke, but nicotine remains a highly addictive, mood altering drug that can cause blood clots, raised blood pressure, increased heart rate, muscular tremor and breathing difficulties. The push is to make smoking acceptable, even glamorous again, with it’s new ‘safe’ form. Harm reduction however doesn’t address the underlying issues: why you need a high in the first place?

And secondly, we cannot go on talking about paying for new NHS services without a fundamental review of what the NHS is for, on which I have written previously. Decisions about funding e-cigarettes should not be being taken in isolation: we desperately need a review of what the NHS can and should provide. I have no problem with people moving to e-cigarettes from the traditional tobacco variety, they will save themselves a lot of money, but it should not be at our cost and without a wider debate.

Credit: IDF

A vote will be taken today on an amendment that has been tabled to the Children’s and Families Bill by Labour Peers to ban smoking in cars when children are present. This isn’t the first time this idea has been proposed, and it will have cross party support in the Lords as the last attempt was a Private Members Bill introduced by Conservative Lord Ribeiro in 2012. The health arguments against exposing children to smoke -and of course the everyone is at risk – are well rehearsed, and neatly summarised here by the BBC. It is worth reflecting however why we need this law.

Much as I recoil from the thought of more legislation to dictate our behaviours, I also accept that we have brought this on ourselves. Over the past few decades we have seen the rise of liberal individualism and mistakenly seen it as an expression of, rather than a threat to, individual liberty. We have been blinded by the entitlement of choice, rather than seeing through to the consequences of choosing. What remains important is not choice per se, but what we choose, and unless we make choices for the common good we delude ourselves that we can remain free. As the brilliant former Chief Rabbi Lord Jonathan Sacks expanded in his ‘Politics of Hope‘, freedom is a moral achievement; it rests on self-restraint and regard for others.

The freedom to protect our children simply because it is the right and moral thing to do has been abused, so it is only right that legislators now step in to enforce the right of children to be protected from smoke.

Today’s report from Macmillan Cancer Support and the National Cancer Intelligence Network (NCIN) on the reality of long-term survivorship from cancer of those over 65 years is contrasted with the larger numbers of survivors in the EU than in the UK. For the over 65′s in the UK, our five year survival rates are lower than in comparable countries. It would seem that the adage “what do you expect at your age?” is alive and kicking in too many hospitals, where the nature of a patient’s cancer and their fitness for treatment is given secondary consideration.

Most commentators still think that age should be a consideration. Having worked with older people for 20 years I would disagree. Fitness for treatment and the nature of the cancer should be the top considerations, never age. The huge variation in well-being of the over 65s would make any fixed age-based decision completely arbitary. More so, if we open the door to age inequalities – making relative decisions based on how old someone is – the economic pressure of an ageing population means that we will inevitably become more utilitarian. A decision based on age harms us all, because it reinforces the idea that your worth is relative to your abilities, your independence and the time period for which you have already lived. 

Jeremy Hunt rightly highlighted last autumn our national shame that so many older people are lonely; he talked about the ‘reverence and respect’ that he had seen for older people in Asian countries. I too have seen this in my visits to sub-Saharan Africa: older people are esteemed, yielded and listened to. We demean our society when we treat older people as inferior.

This subject isn’t going to go away. The organisation that rations our medicines, NICE, are about to start a consultation on how to allow for ‘societal benefits’ as they consider their equation for establishing the cost-effectiveness of new medicines. Last year they turned down all but one new cancer drug, hence the medical and political imperative for the Cancer Drugs Fund. And this was the concern behind the press headlines two weeks ago, stating that older people will be denied drugs as society has less to benefit from an older person compared with someone of working age.

I have already stated publicly that age should not be a consideration in the methodology of assessing new medicines, and the same goes for any treatment. If we are of value because of our humanity, then that is not age-dependent. If we start to make our value conditional on our abilities, then we embrace relativism. We would be opening the door to the discrimination that follows, wielded by those who have the most power, and we would end up with a culture of fear.

However we have another suggestion to help make these ideas happen. When you look through the list of 21 National Clinical Directors (NCD), one thing really strikes you: there is one NCD for mental health; 20 for physical health. If we are serious about parity of esteem, then we need to signal that from the top. Mental illness is not homogenous: PTSD is not the same as post-natal depression, is not the same as clinical depression, is not the same as schizophrenia is not the same as bipolar disease etc. Just because it doesn’t usually require surgery, and just because much treatment isn’t medical either, it doesn’t mean that we shouldn’t take a focused approach.

Whilst the political direction of travel is ‘whole person care’ (and of course care should be holistic), as health guru Michael Porter says, a high value health system still needs “teams focused on specific conditions or population types”. The logical next step for mental health is to have NCDs appointed to represent the main areas of mental illness. We may not need another 19, but parity of esteem will not happen while we have only one (excellent though she is!)

• The public did not know about the compilation of a national database of personal medical information.
• The process took an opt-out approach, but as no one knew about it, how could they?
• The public have been promised access to their online GP record by 2015, but the Department of Health estimates less than 5% will be able to do so. Our records will remain secret to most of us, which means we won’t know what has been written about us, or be able to comment on its accuracy before it is uploaded to the national database.
• Without access to our own records online, we have no access to any audit trail of those who have accessed our data.

The public were unaware of this initiative, supposed to be totally transparent, until the process was stalled last October. Along with some GPs, their Local Medical Committees and MedConfidential, we were concerned that the public knew nothing. We hosted a debate on the subject at the Party Conferences in autumn 2013 after which the uploading of data was delayed whilst a publicity campaign was put together.

Leaflets are now landing on a doormat near you. But there is no encouragement to check your records before they are uploaded; no clear guidance how to opt-out (other than ‘talk to your GP’) and questionable assurances of safety. This is uncharted territory and the governance in place is not as tight as it should be. Why isn’t data being anonymised before being uploaded? It’s not going to take a genius to triangulate personal medical data with that already held by insurers and or employers, by Tescos and or research organisations, especially if you are the only person in London SE5 with Gaucher disease or any other rare condition.

I think the potential for a national database of medical information is an enormously beneficial one, a unique opportunity due to our national health service. Delivering better care is important, no matter who is providing it. But we are being too hasty. Genuine questions of confidentiality, consent and consequences are being batted away instead of being taken seriously. This was even the subject of last week’s Nature editorial from which I quote:

Maximizing the number of people entering the programme is clearly a noble goal. But one cannot help but get the uncomfortable impression that, in their enthusiasm to amass these data, the authorities are using sleight of hand and paying lip service to the principles of informed consent. Inconvenient as it may be, and even if it has some negative effects on the utility of the database, the opt-out option to care.data should be prominently displayed, and facilitated.

Commercial gain from patient data has a historic precedent, but so has the exclusion of the same patients from personal benefit, as chronicled in The Immortal Life of Henrietta Lacks. It is vital that we address all these concerns properly. It is not an overstatement to say that we risk both public confidence in the future of the NHS, and an unprecedented opportunity for genuine medical research if we don’t get this right.