Change the system…

primary_care_training_antibotics

A man has a sore throat. Where he lives it’s possible to buy penicillin over-the-counter.

He gives himself, not enough to kill the streptococci but enough to educate them to resist penicillin. He then infects his wife who gets pneumonia and is treated with penicillin.

As the streptococci are now resistant to penicillin, the treatment fails and the woman dies.

Who is responsible for the woman’s death?

This question was posed by Sir Alexander Fleming, in his Nobel Lecture in 1945 and is repeated in an excellent Penguin Special, ‘The Drugs Don’t Work’, by the CMO, Dame Sally Davies.

For £4.99, it’s the best five quid’s worth of information you can get explaining the anti-biotic crisis we are heading for.

Speaking in Davos, last week, No18 said;

‘Each and every one of us benefits from antibiotics but we… take them for granted… I shudder at the thought of a world in which their power is diminished.

Antimicrobial resistance is as big a danger to humanity as climate change or warfare. That’s why we need an urgent global response.’

The government’s plan aims to control and contain antimicrobial resistance by 2040, reduce the use of antibiotics in humans by 15% over the next five years and cut antibiotic use in animals by 25% from 2016 levels, by next year.

Dame Sal’ wrote her book in 2013 and the dangers were known well before that. We have seen umpteen attempts at sorting this out.

No18’s latest wheeze is a new payment model that means pharmaceutical companies will be paid for drugs based on how valuable the medicines are to the NHS, rather than by the quantity of drugs sold.

This, of course, is a bonkers idea and will drag us into all sorts of argy-bargy over how to evaluate ‘value’.

The most expensive NICE approved drug on the NHS is Eculizumab, £340,000 a year; prescribed for a rare blood disorder. The annual cost is £82m and gives patients an estimated 25yrs of independent living.

It has huge value to the patients and their families.

Compare that to a new antibiotic that rids us of infection and allows operations to be carried out safely.

In primary care, alone, in a year, there are about 5 million prescriptions for antibiotics. Penicillins account for roughly half, mostly for infections of the respiratory and urinary tracts.

Population based value; Eculizumab benefits 200 patients. A new penicillin could benefit millions.

Value based pricing means Eculizumab would cost a fiver and pills of penicillin+ would cost more than a hen’s gold-tooth. Pharma-co’s would have a field day.

There is another way.

NICE have evaluated a near patient testing device to determine if an infection is microbiological or a virus. The test is widely used across Scandinavia and Germany.

In two minutes it’s possible to see what’s what.

The problem; the test requires reagents. The average cost of a course of amoxicillin is approximately £1.49. The cost of the test, plus reagent, is about £4.

Change the system, the reimbursement incentive, so that no one gets a prescription until the test has been done. Yup it has a cost but the alternative is a price to pay, for all of us.

The next possibility might be a Brexit bonus.

Across the EU a pharma patent lasts for 20 years. The clock starts ticking when the company registers the molecule and starts carrying out exhaustive tests, which take years and years, brings the drug to market and must recover their costs and make a profit before the patent runs out…. pushing prices up.

Change the system; in the UK we could make our own rules and extend patents for anti-microbials for a longer period.

A popular song is copyright for 50 years, let’s start there. Double the patent life for a drug and give pharma longer to amortise their costs.

Price controls could ensure they don’t cheat.

Sally Davies’ book says ‘the drugs don’t work’ and that is, in large measure, because the system doesn’t work…

… so change the system.

Contact Roy – please use this e-address – roy.lilley@nhsmanagers.net
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Reproduced at TrainingPrimaryCare.com by kind permission of Roy Lilley.