2008 marks the 60th anniversary of the establishment of the National Health Service (the NHS) in the UK. While it has undoubtedly served the British public well in that time, the five part BBC1 series Dom’s on the Case continues the current trend for documentary programming which investigates inequalities with the NHS system, specifically geographical inequalities which arise from the so called ‘postcode lottery’.
Previous BioethicsBytes posts have highlighted resources which have examined this issue in detail (including The NHS Postcode Lottery: It Could Be You – Panorama and Herceptin: Wanting the wonder drug – Panorama), so here we highlight some additional issues raised within the third episode of Dom’s on the Case, which was first broadcast on BBC1 on Wednesday 24th September 2008, at 09.15. In this 45 minute programme, reporter Dom Littlewood highlights some of the inequalities which arise from differential prescription charging and access to drugs across the UK. While the programme’s tone may seem excessively negative – insofar as it presents only the perspectives of aggrieved patients and members of the public – it offers a number of short clips which provide concise descriptions of the various sources of inequality. Further it highlights the extreme measures that some patients feel forced to take in order to “beat the postcode lottery” (00:10:05) and access the drugs and treatment they feel they deserve.
Beating prescription charges
At the time of broadcast prescription charges varied across the UK: as Dom’s on the Case reports, they are currently £7.10 per item in England, £5.00 in Scotland and free in Wales. It was apparently this discrepancy (alongside the free parking at NHS hospitals that is provided in Wales) that led the village of Audlem in Cheshire, which lies 10 miles from the border with Wales, to petition the Welsh Assembly to become part of Wales, and hence entitled to free prescriptions (see 00:02:28 to 00:05:34 and 00:38:48 to 00:41:01). Unsurprisingly, the village’s case was rejected, however the programme uses this extreme example of one way to beat the postcode lottery to highlight the wider effects of prescription charging in the UK. In particular the episode looks at patients with chronic conditions who may feel unable to pay the charges for some or all of their prescribed medications (for interview footage with a Citizens Advice Bureau representative on this issue see 00:18:10 to 00:19:06).
The programme also highlights another source of inequality in prescription charging. Dom Littlewood refers to a list compiled by the NHS in 1968 which specifies a number of chronic conditions for which medication is provided free of charge. The implication here is that, although certain social groups get free or discounted prescriptions, a blanket prescription charge is still unfair because it fails to take into account the situation of the patient and their ability to pay for what may be multiple items over a number of months or years (see 00:15:01 to 00:18:03 for a comparison of patients with differential access to free of charge prescriptions).
One of the unique features of the Dom’s on the Case series is that, in addition to exploring some of the inequalities in health service provision across the UK, it attempts to provide some ‘solutions’ to these problems. In the case of prescription charges, these are a set of strategies individual patients might adopt in order to minimise the cost of their prescribed medication. These include pre-payment and asking the doctor for longer prescriptions for which the patient only pays one charge. Another of the strategies suggested by Dom Littlewood involved exchanging prescribed medication for cheaper over-the-counter alternatives on the advice of a local pharmacist. While this advice may be useful in principle, the coincidence of this programmes broadcast and the publication of a Which? report into medical advice given through pharmacies (see the BBC News report entitled Pharmacy advice ‘frequently poor’), suggests caution when putting it into practice.
Accessing “life saving” (00:08:09) drugs
Previous BioethicsBytes post have dealt at length with the conditions that result in differential access to drugs that are pending approval by the National Institute of Clinical Excellence (NICE), and as the title of our most comprehensive post on this issue (The NHS Postcode Lottery: It Could Be You – Panorama) suggests, these are some of the most frequently cited example of the ‘postcode lottery’ in action. In this episode of Dom’s on the Case it is the differential provision of the cancer drug Sutent (generically, Sunitinib) on the NHS that is highlighted. Sutent is treatment for advanced and metastatic kidney cancer. It is life extending, however, according to this programme, costs around £120 per capsule and up to £30,000 a year (see 00:07:20 to 00:08:15 for full details). In the cases of both patients featured in this episode, their respective PCTs had rejected their applications to have Sutent prescribed on the NHS: for the first, it seemed that he had not proved himself to be an ‘exceptional case’; in the other, the PCT had simply claimed that “they don’t have enough money for drugs that haven’t been approved by NICE” (00:14:02).
Here again the programme offers some strategies for beating the postcode lottery, though this time in the form of the actions taken by each of the two patients featured. The first patient – who had chosen to pay privately for the medication – takes advice from an experienced ‘health campaigner’ on the possibility of appealing to the PCT that initially rejected his application. The second patient effectively relocates in order to circumvent the process by moving from the PCT area that rejected his application for Sutent provision, to an area whose PCT has history of providing Sutent routinely on the NHS. The programme follows each patient and highlights some of the effect of their choices on their lives and their families (see 00:19:11 to 00:25:19 and 00:30:54 to 00:33:35 for the first patient’s story; and 00:10:12 to 00:13:59, for the effects on the second patient).
While this programme is useful in highlighting the effects on and experience of patients who feel they are being treated unfairly by the NHS, this episode of Dom’s on the Case does only present one side of the story, and in this sense gives an incomplete picture of the complexity of resource allocation with publicly funded healthcare systems (particularly in its implicit condemnation of NHS funded health promotion initiatives and respite care arrangements – see 00:25:52 to 00:30:03 for details). It does, however, re-emphasise the main the point made in our previous BioethicsBytes posts: that concerns over issues like prescription charges and decision-making by PCTs on drugs not yet approved by NICE all appear to boil down to the same basic claim that, within what is supposed to be the National Health Service founded on the principle of equality of access, it is not fair that some people have to pay while others do not.
This espisode of Dom’s on the Case was first broadcast on BBC1 on Wednesday 24th September 2008, at 09:15. It can be viewed on the BBC iPlayer website until Friday 3rd October 2008. Members of the BVFUC can obtain copies via TRILT (TRILT identifier: 00B3F025).