Has the NHS forgotten that it is there to CARE for patients? Write to your hospital!

First published 13 April, 2012, on Mail Online

The Times research yesterday revealing that up to 400,000 people a year are discharged from hospital at night is shocking.

Whilst a few patients will be mums who are going home after giving birth and some are sobered-up louts who had been admitted for observation, as 70 per cent of hospital in-patients are elderly the majority of people effected will probably be over 65.

Has the NHS forgotten what it is there for? Yes in the 21st century we have rapid action medicines and clever diagnostic technology that identify problems and restore vital signs to normal but at the heart of health should be caring.

‘Do no harm’ is the first part of the Hippocratic oath and this doesn’t just refer to the physical, but to spiritual and emotional health as well.

Many people will conclude from this report today that we’re now spitting people out when the technical, medical treatment is finished, forgetting that we’re dealing with human beings, not machines.

Although the stories are shocking, if we consider the state of our culture maybe we shouldn’t be surprised.

There has been an erosion of caring as being central to our societal values. It has been downgraded, regarded as a second-rate activity which gives us a key reason as to precisely why we have crisis after crisis in hospitals and care homes.

We need to remember that some anthropologists have now concluded that the first real signs of civilisation are not when man-made tools are found, but when they see evidence of a healed bone fracture.

A healed fracture indicates that a human being was fed and attended to until they recovered.

To reverse our decline, the holistic care for body, mind and spirit that is given to people in hospices now needs to become the model for all institutional care organisations and medical training.

The government also need to take note that these findings today make a mockery of patient choice. We keep hearing from politicians about patient control and ‘no decision about me without me’ but the reality is that often we are given no choice about the circumstances of our care.

Every hospital Board should now be looking at their figures and taking a leaf out of Newcastle Hospitals’ book not to discharge patients at night. The NHS was created to remove fear of not being cared for: are we going to stand by and allow fear to return?

The elderly should have the peace-of-mind in their older years and its down to all of us to do what we can to ensure this. In the light of this report, a first step could be that each of us lobby our local hospital to get an agreement that they will not discharge any elderly person at night.

There is a letter that you can download from the 2020health website. Let me know if you make progress!

Obamacare and the Supreme Court

By guest blogger, Tom Packer

As we have seen Obamacare is a radical reform to the mixed system of healthcare in the United States , and one that is  highly politically contentious.  It has also become legally contentious.  For over a hundred years it’s been accepted in the United States that the federal (that is national) government’s laws can be essentially overturned by the federal courts for being unconstitutional, that is that congress has tried to do something it legally cannot that is ‘unconstitutional’.  Increasingly for better and for worse the existence of concepts like ‘European law’ make the British situation much more analogous.  Thus seeing how the courts consider healthcare policy in the United States – including their response to political pressure is probably increasingly relevant for those of us in the UK.

In the case of Obamacare the majority of the states have now sued to have the law declared unconstitutional.  After clashing rulings by lesser court it has now just been heard at the end of last month in the Supreme Court. The court’s ruling is expected in June.

The challenges which have got as far as the supreme court are challenges to two different aspects of the law.  The first is against the individual mandate – the requirement to purchase insurance (or face a fine) which as I have previously explained is fairly central to the operation of the law.  The second is that the conditions attached to the expansion of Medicaid ( the state run programme for relatively low income people’s healthcare)  unconstitutionally ‘coerce’ the states. I will focus on the first challenge because it cuts closer to the heart of the law, has more complicated legal issues and in my opinion is more likely to succeed.

The  basis given by congress when passing the individual mandate was the ‘commerce clause’. This states that Congress has power ‘To regulate Commerce with foreign Nations, and among the several States, and with the Indian tribes;’ Another clause of the constitution  (the ‘necessary  and proper’ clause)  gives Congress the power ‘To make all Laws which shall be necessary and proper for carrying into Execution the foregoing Powers’ .

On the face of it a requirement to buy a product for all Americans might not seem to flow naturally from such a provision. However it’s important to realize how broadly the Supreme Court has come to interpret the power given by the Commerce clause since the 1930’s. In the case of Wickard v Filburn it was stated that Congress had the power to ban a farmer feeding himself with corn he’d grown because of the knock on effect  on attempts to control commerce in corn. This ruling was arguably upheld recently (2006)  in Gonzales v Raich where a ban on  the use of marijuana was upheld as necessary for a ban on drugs crossing state lines though the plaintiffs did not challenge the  ban on exporting drugs. Most of the  US government’s regulation of the US economy and society has been based on this ‘strong’ commerce clause. This has been true of issues as varying as racial policy and the regulation of wetlands.  Even assuming the Supreme Court was in favour of repealing the modern American regulatory state it is unlikely they would risks the political backlash- and the threat the court’s power would be broken by changes in the law (that nearly happened the last time the court took a strong stance on the commerce clause in the 1930’s)

On the other hand there has in recent decades been an attempt by court to ‘recreate’ limits to the power the commerce clause gives congress to control activities.  A key case was in 1995 when in the case of  United States V Lopez a law was struck down banning  carrying guns using the commerce clause powers.  The court ruled carrying guns near a school was just too distant from the activities of commerce to count.

This gives some ground for thinking the court might overturn the mandate.  Particularly because it could be done on the grounds that the commerce clause does not give the power to create commerce as oppose to regulate or ban.  Thus the supreme court would be able to give teeth to the commerce clause without overthrowing the regulatory state of the last 80 or so years.  Indeed no act of congress has compelled the purchase of a product under the commerce clause before so it could be argued they would only be stopping further expansion in the clause’s meaning.

On the more brutal and obvious political level the mandate itself is unpopular – so the chances of attacks on the power of the court or the status of the justices would be reduced.

There are well thought out arguments on the other side of the issue.  One is that the mandate is necessary for the rest of the law to work and that is a proper exercise of congress’ power to regulate commerce (which does raise again the question of whether this sets any real limits on the power of the commerce clause).  Another argument is that healthcare is a distinctive product in that everyone by being alive becomes part of the market so the mandate is  merely a regulation of the market (like the law forcing healthcare providers to treat the critically ill).  This suffers from issues of definition (where does ‘healthcare’ end?) and again is not a very obvious limiting principle – why would it not apply even more clearly to the purchase of food for example.  Another textually is that the mandate is a tax break (that is it’s a tax on everyone with those buying insurance exempted) and justified under the federal government’s undoubted power to levy taxes. However this suffers from complications as to whether it’s a constitutional form of taxation and also from the fact that the mandate applies to various people exempted from the fine.

Perhaps the strongest ‘political’ reason the court might not strike down is through the complex topic of ‘Severability’.  That is, if the mandate is struck down what parts of the law survive? This is rendered particularly complex question because Obamacare lacks a ‘severability’ clause that is a clause stating what aspects of the law survive or fall if other parts of the law endure.  It’s not clear if it was a mistake not to have one – or an attempt to protect questionable parts of the bill legally  by attaching them to the whole bill.

There are essentially three basic options on ‘Severability’ for the Supreme Court in the event they declared the mandate unconstitutional.

1. The Supreme court could strike down the mandate and let the rest of the law stand. As  previous explained  the loss of the ‘mandate’ is likely to lead to the destruction of the US insurance industry and spiralling premiums for healthcare  as people only sign up when ill (at the state level this has tended to end up with the repeal of such mandates). The court is likely to be very uncomfortable about this and may be worried they would get political blame as well.
2. Get rid of the parts of the law most obviously served by the mandate – the ‘community rating’ which a common price for health insurance people regardless of risk, cost etc. Of course if the court does this they risk being blamed for getting rid of the most popular aspects of the court.  That may well be why this is what the Obama administration has argued is the case if the mandate is repealed.
3. Get rid of the whole law and treat the mandate as sufficiently central to the law as to justify invalidating the whole law in the absence of a severability clause. This risks making the court look highly partisan and political

One (probably) minor note is in theory the court could refuse to rule on the constitutionality.  This is because of the ‘Anti-injunction act’ which bans suing against a tax until it’s been levied (this is to prevent tax collection being paralysed by lawsuits ).  Even leaving aside the arguments against the mandate being at tax it’s worth noting the Obama administration has argued the act does not apply, there’s a very strong case that it’s possible for the US government to waive any protection from it and finally I think the court would be wary of creating so much uncertainty on the management of 15% of the US economy.

The Medicaid expansion argument will be dealt with more briefly.  It essentially boils down to the argument that because of the enormous sums involved the Medicaid expansion unconstitutionally ‘coerces’ the states – because they lose so much money (paid for out of taxation by the citizens of all states including the states) if they refuse the conditions.  It relies on a single sentence of a 1987 cases which suggests this is possible in principle.  It’s quite difficult to establish how this is different from Medicaid as currently constituted in principle, even some very conservative legal scholars argue against this being ‘coercive’  and there’s a valid case that the more money attached to conditions the less ‘coercion not more.  On the other hand the court has shown a real concern with upholding ‘the dignity’ of state governments.

So how will the Supreme Court rule?  It’s certainly very difficult to predict. Most experts seem to conclude the court will refuse to invalidate any of the law.  My own view (given with very little confidence) is that the desire to give meaning to the commerce clause and prevent further expansion will lead to an invalidation of the mandate with the rest of the law left to stand.  However virtually any result is very plausible ranging from the whole law being upheld to the whole law being struck out.

Thus the stakes for Obamacare at the Supreme Court are very high indeed.

Our leaders need to learn from the Lady of Downing Street

First published 30 March, 2012, on Mail Online

There was once a lady who lived in Downing Street. She had married a wealthy man and worked incredibly hard, wanting to ensure that people were provided for at a time when there were very few women in senior public positions of leadership.

She regularly hosted free meetings of the great and the good to enable an exchange of views. However she also made a point of inviting people from low-paid and menial roles to hear presentations, ensuring that they too had an opportunity to influence and be influenced.

Such were the popularity of her meetings that she had to have them in a larger house near Hyde Park corner as well. It was the custom of the day to serve soft drinks, cold meats and pasties to guests who were more accustomed to quaffing wine and liquors.

And despite inviting some very controversial speakers to address her guests, she shunned the insults and contempt shown to her by some of her peers. She knew her class was a barrier but she didn’t let that stop her meeting and seeking the help of those from all walks of life.

In 1740, the philanthropist Selina, Countess of Huntingdon was a resident of 11 Downing Street. From being one of the original donors of the Foundling Hospital for the poor, to bank-rolling the emerging, scandalous (at the time) Methodist Wesley brothers and paying for sixty-four chapels to be built nationwide, her approach was one of sacrifice and her attitude was one of being in the service of God.

Becoming a widow at a young age and losing five of her six children in her lifetime never stopped her for long before she once again turned her eyes outwards to see what she could do for others. In her will she stipulated that no biography should be written of her, and no use made of her many letters. A few brave souls have risked her displeasure and ensured that she doesn’t remain in complete obscurity.

After the pasty, petrol and pay-for-access week we have just had, it seems to me that the current residents of Downing Street could learn something from Selina.

Dementia remains a terminal illness and it is right to invest more in research

First published 26 March, 2012, on Mail Online

Notwithstanding Meryl Streep’s superb performance, politicians publicly expressed disquiet when ‘The Iron Lady’ came to cinemas in January. Although the historical inaccuracies merited some comments, the subject that caused the most controversy was the portrayal of Lady Thatcher with dementia. Film-makers, they said, should have waited until she had died before depicting her as a frail lady with memory loss.

As I asked back in January, why? One in five of us who make it beyond the age of 80 will suffer with dementia (a mental illness over which we have no control) and frailty and increasing dependency will come to us all. There is no shame in this.

Today the government have announced that they will double the research spending on dementia. This is welcome and well overdue, although it still leaves unanswered the question of how we afford the social care support for those who develop dementia.

 

Three years ago when I was researching for a paper on new technologies and medicines, I came across two startling facts:

The first was that we spend eight times as much on cancer research as we do on dementia research, and much less proportionally in the UK – the equivalent of £7 per person as opposed to £52 per person in the USA.

The other shock was that there was no new approach being developed in research. In other words the focus of research is on how to modify and hopefully slow down the rate of disease progression, not cure it.

That is the hard truth with dementia – it is still a terminal illness with the average life expectancy after diagnosis being eight years. The attitude from many professionals has therefore unfortunately been one of resignation: what’s the point of diagnosing something you can’t prevent; or considering memory loss to be par for the course in older age?

In some groups being diagnosed with dementia is considered a stigma, and professionals can avoid investigations for this reason – but to be fair some individuals deliberately avoid the doctor, not wanting to be told or fearing they have dementia.

Hopefully this new announcement and the accompanying publicity will encourage greater diagnosis of the condition, especially as recent research has shown that the current treatment available is effective in slowing down the rate of progression in those with early stage disease as well as those who have more advanced dementia.

It’s a tragic disease which is no respecter of rank, but as well as investing more in research I hope the UK can also take an international lead in the way it takes care of those who suffer.

An inadequate alcohol strategy in the face of a national crisis

First published 23 March, 2012, on Mail Online

Yvette Cooper gave a superb response to the Home Secretary Theresa May’s announcement of the government’s alcohol strategy this morning in Parliament.

However Yvette was wrong in one respect; alcohol misuse IS a national crisis. It’s a crisis for women and children: Drinking adversely affects up to 1.3 million children in the UK with police estimating that 40% of all child abuse and 62% of domestic violence incidences are directly related to alcohol. In a survey last year, it was found that 4% of 12-13 year olds had themselves had drunk 28 units (roughly 3 bottles of wine) in the previous week.

It’s a crisis for the economy: the costs of misuse to the public purse are estimated to be between £20bn and £55bn annually. It is hard to quantify as we can count some of the direct health, crime, family breakdown, violence and lost working days, but the figures don’t include the lifetime care of a child born with foetal alcohol syndrome or the fallout from a fatal crash caused by a drunk driver.

And it’s a health crisis: 7% of all hospital admissions (about 1 million people) and 35% of A&E attendances are due to alcohol. Our casualty departments are overflowing with intoxicated adults and staff are being deployed in A&E who should be looking after the sick and elderly. Our liver disease in the UK has increased by a quarter to a half in the past 10 years whereas elsewhere in Europe it has been falling. Throat cancer is rising and alcohol is the prime suspect.

We desperately need a comprehensive alcohol strategy that will address all causes of alcohol misuse. What we have heard announced today is simply inadequate. Much as I applaud the proposal for minimum pricing (being able to get drunk for under a pound is ludicrous),the focus of the strategy seems to be on binge drinkers and alcoholics, who make up the minority of the people who are drinking too much.

In the report produced by 2020health, the Think Tank that I run, we highlighted the fact that a quarter of all adults – 8 million – are drinking too much alcohol. We called them the silent majority, hoping to loudly expose the problem! Many have no idea that their daily drinking (they don’t get drunk) will result in a health crisis later in life in the form of cancer, stroke or liver disease.

We have incredibly inadequate information, most people have no idea how many units there are in a drink and the tiny, low contrast unit labelling that industry sometimes puts on the back of cans and bottles doesn’t help as it is virtually invisible.

So how about GPs asking about alcohol as routinely as they do smoking, and offering an advice session known as a ‘Brief Intervention’ to those who are drinking to excess; how about having compulsory unit labelling, clearly on the front of bottles and cans, as we have with cigarette packets; how about a public health campaign educating us so that we all know two large glasses of wine a day can equal 6 units and that this increases risk of liver disease sevenfold, mouth cancer fivefold, stroke threefold and doubles the risk of breast cancer?

And how about  an urgent review of advertising of alcohol – we are still bombarded in this country with drink advertisements in ways that have been outlawed elsewhere in the world.

Whilst making city centres safer and promoting peaceful night-life is important, Durham and Nottingham have shown that this is already possible and achievable without any changes in the law. Many pubs already promote sensible drinking and are playing an important role in their communities.

Our alcohol crisis in the UK is a daily catastrophe. Libertarians will whinge about regulation and the unfairness of minimum pricing (as if supermarkets loss-leading on alcohol and charging us more for other goods is fair)  but as ever they want all the individual licence without the social responsibility.

The crisis speaks for itself – we are failing the vulnerable and allowing an unhealthy, under-productive society to persist. We needed a comprehensive alcohol strategy to transform England and we didn’t get one today.

Sunday trading fails Cameron’s family test

First published 19 March, 2012, on Mail Online

Before the last election, David Cameron said that he knew that ‘reviving society’ was as important as reviving the economy. He talked about transferable tax allowances for married couples to recognise the social importance of marriage and the commitment of time taken out to be a full-time parent. He re-envisioned ‘loving your neighbour’ as the ‘Big Society’, with citizens taking back power from the state to volunteer or run co-operative organisations.

But as the news broke at the weekend that extending Sunday opening hours was part of the vision for economic revival and supply-side reform, I couldn’t help but wonder how the Prime Minister reconciled this with his determination to ‘revive society’?

George Osborne claimed on the Andrew Marr show that to keep Sunday trading times as they are sent the message that Britain was ‘closed for business’. It seems to me that extending them sends the message that we are open for exploitation.

Take those who already work on Sundays in the big retailers. It is totally naive to think that they will be given a choice over whether to work longer. With our unemployment levels and ineffective employee safeguards, people will have to work longer or risk losing their job. And as the large retailers open for longer, smaller retailers will feel greater pressure to extend their opening times – there aren’t many levels on which the small guys can compete with the large boys but opening times has been one of them.

Instead of reviving society this will lead to the coercion of thousands of people into leaving their families for the entire two days at the weekend.

We already know through the outstanding work of Sir Michael Marmot that those who lack status in the workplace, i.e. those who have little control of their work circumstances, are those who experience the greatest inequalities. Imposing longer hours will make the situation of shop-assistants, some of the lowest paid, worse. We are stretching their resilience to breaking point; many families struggle already with parents holding down and juggling family needs with two or more jobs each. This proposal will impact childcare, access to healthcare, educational support and thus children’s long-term life chances.

Added to this the vision for the Big Society is dependent on people having the time to give to their communities: to know that they are needed beyond their workplace and front-door. If we have economic policies that increase inequalities and societal burden, the opportunity for people to be the ‘needed’ part of the Big Society will diminish, thus increasing not reducing their dependence on the state.

I’ve thought about the impact on where I live in Peckham. Local people won’t have any more money to spend; there will be no extra Olympic visitors contributing to the legal economy here. Yet the burden of extended opening hours will be felt by those on small wages and low status. There will be greater pressure on families, and in a community with a large Christian, ethnic minority presence, the support given by community gatherings at church on Sunday will be diminished.

This is a bad proposal. Economists may see the Sunday trading restrictions as red tape, but the whole thrust of Cameron’s pre-election narrative was that there should not be a trade-off between economic and societal gain. Last August he said, ‘from here on I want a family test applied to all domestic policy. If it hurts families, if it undermines commitment, if it tramples over the values that keeps people together, or stops families from being together, then we shouldn’t do it.’ It is a good test, this proposal fails it, and George needs to find more creative ways of declaring the UK open for business.

Guest Blogspot: Pharmaceutical R & D – the value of radical innovation versus incremental progress

What we really want is affordable products that benefit patients, whether or not they are “innovative” in the usual sense of the word. Scientific innovation is not a medical end in itself. The ultimate aim of pharmaceutical R&D is to discover important new medicines, which can either be new drugs replacing older, inferior products or treatments for illnesses where no drug previously existed. Giving higher prices to more valuable drugs is not the only way in which the pricing system could set out to encourage pharmaceutical R&D. Companies with important new products ready to launch are not the ones that most need encouraging to sustain or add to their R&D spending.

The generally accepted definition of “innovation” is about how new, different or unexpected an invention is, not about its value, usefulness, price or affordability. Sir Michael Rawlins, Chairman of NICE, has defined innovation in the NHS differently, as a product or process that “significantly improves healthcare at a price the NHS can afford”. If we work using his definition, then the new drugs that we want are necessarily “innovative” but only because of the way in which he defines the word. In this blog we use the terms “innovation” and “innovative” with their normal meanings because Sir Michael Rawlins’ use of the words is unusual and could be misinterpreted.

We must never forget that in medicine the aim of R&D is to help find ways of meeting previously unmet medical needs. An innovative drug is of no use if patients cannot be identified for whom it is better than existing products. No drug is of any value if it fails to improve outcomes for identifiable patients or has unacceptable side effects, no matter how innovative it may be. Work that is not innovative is not research. However, R&D should be directed towards trying to improve the treatment of patients as much as possible irrespective of the degree of innovation involved.

The absurdity of trying to value drugs at around the time of launch, of seeking to measure innovation or of predicting exactly what will emerge from R&D is most apparent from looking at case studies. The principles have not changed over time.  Old case studies are the most useful because we know what eventually happened and there are no current commercial interests clouding the debate. In addition, the answers to the key medical questions have generally ceased to be controversial.

The difficult issues involved in valuing innovation or predicting the future for individual drugs are apparent from many case studies. I have chosen to focus first on the development of a class of drug called beta-blockers. The relevant history is one of the classic pharmaceutical R&D stories. Beta-blockers were discovered by Sir James Black, in connection with which he won a Nobel Prize. His work ranked amongst the most innovative ever carried out in the pharmaceutical arena. Beta-blockers cause the heart to beat a little less rapidly and are of value in reducing high blood pressure, in angina, in helping certain patients with irregular heart beats and in reducing the risk of a second or subsequent heart attack in people who have already suffered one. The development of beta-blockers was pioneered by ICI Pharmaceuticals (now part of AstraZeneca), for whom Sir James Black worked at the time.  Other companies have also developed beta-blockers but ICI was the frontrunner and the main lessons can be learned by focusing principally on this company.

The first beta-blocker to be launched by ICI was Alderlin (pronethalol) in 1963. However, this drug was later withdrawn from the market because it was found to cause tumours in mice. The potential risk of the product eventually turning out to cause cancer in humans was judged to be too high to justify long-term usage. A value-based assessment of the value of Alderlin if no improved product had become available would have been very controversial, since the cancer risk would have been considered too great to justify usage outside a narrow group of patients with particularly severe heart problems. The value of the drug to these patients would have been critically dependent on who would have been considered eligible to receive it and on subjective judgements about the extent of the cancer risk.

ICI’s first beta-blocker suitable for widespread use, Inderal (propranolol), was launched in 1965. This drug transformed the lives of many patients, for whom it represented a breakthrough in treating unmet medical needs. However, the degree of innovation involved in its discovery is debatable, since Alderlin already existed and from a scientific standpoint Inderal was conceptually only a small intellectual advance. Nevertheless, Inderal was suitable for widespread use in addressing unmet medical needs whereas Alderlin was not. Unfortunately, this important difference of crucial relevance to pricing would not have been fully apparent when the products were first introduced.

Alderlin and Inderal had the drawback that, as well as reducing heart rate, they also reduced oxygen intake into the body by contracting the lungs. Reduced heart rate and a reduced need for oxygen are closely linked in healthy people and so a connection between the two is not scientifically surprising. However, a reduced oxygen uptake is undesirable in asthma and angina patients. ICI therefore sought to design beta-blockers that worked selectively on the heart and affected the lungs relatively little.

ICI’s first heart-selective beta-blocker was Eraldin (practolol), launched in the UK in 1970. This product was certainly innovative but not to the extent of Alderlin as the latter involved pioneering the beta-blocker drug class as a whole. Unfortunately Eraldin was eventually found after launch to have severe side effects in some patients, including serious eye damage that sometimes resulted in blindness.  The drug was withdrawn from use outside specialist hospital units in 1975. With the benefit of hindsight a value-based analysis should have assessed the value of the drug, as used, at nil (or maybe even at a negative figure on the grounds that the drug did net harm). This conclusion is despite the fact that the product did not cause severe side effects in the vast majority of patients and that many people benefited.

The severe side effects of Eraldin turned out to have been bad luck and not to arise with other beta-blockers. In 1976 ICI launched a successful selective beta-blocker, Tenormin (atenolol). This product became for many years the third best-selling pharmaceutical in the world behind the ulcer drugs Zantac (ranitidine) and Tagamet (cimetidine). Sir James Black received his Nobel Prize in 1988.

Tenormin can be credibly argued to be the least innovative of ICI’s beta-blockers in terms of the incremental work needed to discover it. Yet Tenormin is clearly the one that has done the most to satisfy the unmet medical needs of patients.

Despite the human tragedy relating to Eraldin’s unexpected side effects ICI’s overall beta-blocker programme has definitely made a major net contribution to mankind. The problems of Eraldin could not have been uncovered at the time in any way other than giving the drug to enough patients for the position to become apparent.

Another interesting case study is provided by the ulcer drugs Tagamet and Zantac. Tagamet, like beta-blockers, was the brainchild of Sir James Black. Despite his track record he had to move from ICI to SmithKline in order to gain support for the ulcer project.  This fact alone shows that even companies intimately involved in evaluating potential R&D projects can have difficulty in seeing their potential.

Zantac was a small but real improvement over Tagamet and was developed under one of the all-time great research directors, Sir David Jack of Glaxo. Tagamet was discovered before Zantac and is therefore more innovative. Both drugs work in the same way. However, Zantac is slightly better and so it would be hard to argue that it should have a lower price.  Zantac therefore achieved higher sales even though Tagamet was more innovative. There is no easy way in which SmithKline could have been rewarded for pioneering the drug class with Tagamet when Zantac was a marginally superior product.

The bottom line is that trying to award a higher price to more innovative drugs is fraught with dangers, inconsistencies and unintended consequences. My view is that the best way to encourage productive R&D through the pricing system is to encourage companies to keep going throughout the ups and downs.  Companies should be rewarded for trying, whether or not they succeed. The greatest support is needed during barren periods in R&D. Market forces are already sufficient to ensure that drug companies will direct their R&D towards illnesses where new drugs are needed. Companies also have to consider the worth of their ideas for R&D projects and what expertise they have. The way forward is not for governments to try to impose views on the direction of R&D.

Even ICI did not always fully recognise the value of Sir James Black’s work on beta-blockers. In an autobiography Sir James Black wrote:

“Egged on by their local representative, I successfully approached I.C.I. Pharmaceuticals Division for help and ended up being employed by them at their exciting new laboratories at Alderley Park, Cheshire. During my six years with them Dr Garnet Davey (subsequently Research Director) constantly supported me and, I have no doubt, fought many battles on my behalf to keep the initially controversial programme going.”