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    The results of a survey of PDA members reveals widespread occurrences of patients being unable to afford to pay for the medicines they need. The PDA is a member of the Prescription Charges Coalition, a group of organisations calling on the UK Government to scrap prescription charges in England for people with long-term conditions.

    Currently in the UK all prescriptions are free of charge for people living in Scotland, Wales and Northern Ireland. However, there is a growing body of evidence which suggests that widening the scope of long-term conditions eligible for free prescriptions in England would bring about long-term cost savings for the NHS.

    Paul Day, PDA Director, said “PDA members are naturally concerned when a patient is unable to afford their prescription charges, and tell us they will explain to the patient the consequences and outline available financial support.  However, this is an issue only government can fix.  Patients being unable to receive their medicines is a false economy, as it is likely to cause the NHS more in the longer term.

    For example, a 2018 report by the York Health Economics Consortium, on behalf of Parkinson’s UK and Crohn’s and Colitis UK, found that scrapping prescription charges would save the NHS £0.8 million over 12 months for Parkinson’s sufferers and £20 million for sufferers with IBD over the same period1.

    The report goes on to predict that waiving prescription charges for Parkinson’s and Crohn’s sufferers would also have a beneficial effect on reducing health complications, with 11.4% fewer hospital admissions, 9% fewer A&E visits and a 20.4% reduction in inpatient bed days. On top of these benefits there is also the immeasurable improvement to patients’ mental wellbeing.

    The PDA survey garnered more than 350 responses altogether and the overriding tone was that pharmacists in England believe the system needed an overhaul to become fairer.  There was also support for rolling out prescription charges exemption to cover a wider array of health conditions than currently qualify.

    Over 96% of Pharmacists surveyed said they had witnessed, first-hand, patients refusing to take away a part or whole prescription due to the cost involved. In spite of this initial refusal, 90% of Pharmacists still used their professional knowledge and judgement to educate the patient and persuade them of the benefits to be gained by purchasing and taking the medication. However, if the patient does not have the money to pay for the prescription, these discussions can be extremely difficult for all concerned.

    These are situations in which Pharmacists do not receive a lot of training in and yet, in light of the current economic climate, is a conversation which could become all too familiar to our members as the general public look to cut back on spending as the economy suffers due to the pandemic.

    Almost all Pharmacists that responded to the survey said that they recommended prescription pre-payment certificates to patients that struggled to meet the costs of their prescriptions, demonstrating an active willingness to do what is right by the patient in light of a system which 90% of respondents described as “unfair”.

    Most pharmacists supported a widening of the long-term conditions eligible for prescription charges exemption, but there was also significant support for limiting the exemption exclusively to medications relating to the patient’s long-term health. Over 80% of Pharmacists in the survey felt that broadening the range of patients eligible for free prescriptions would lead to a reduction in incidents where patients decline prescriptions due to financial constraints.

    Laura Cockram, Head of Policy and Campaigns at Parkinson’s UK who chairs the Prescription Charges Coalition, said: “We are grateful to the PDA for their contribution to the work of the coalition and to pharmacists for the work they do every day supporting people with long term conditions. We believe that together we can convince the government to remove these unfair charges in England for people with long term conditions.

    Lynne Regent CEO of the Anaphylaxis Campaign, said: “For the people we represent, being unable to afford the cost of their medicines can mean that their life is at risk if they have a severe allergic reaction and have not been able to afford to pay for the prescription for their Adrenaline Auto Injectors.

    Alison Taylor, Chief Executive of the Children’s Liver Disease Foundation: “For most children and young people with a childhood liver disease, daily medication is lifelong and life-saving. Unfortunately, prescription charges are introduced at a time when young people are transferring from paediatric to adult hospital services and also when they are trying to budget to become more financially independent. This additional cost is an added stress and we cannot risk these patients cutting costs by not taking their medication, especially those on immunosuppressants. Prescription charges are viewed as deeply unfair by our community as our young people are forced to pay for essential medication when others with long-term conditions do not have to. Medical exemption certificates are only available for a very limited range of conditions, based on a list that was produced in 1968 and is largely unchanged.

    See the survey result analysis here:

    thumbnail of PCC survey analysis

    References: Prescription Charges Coalition. 2018. The cost to the NHS of prescription charges for people with long-term conditions. [ONLINE] Available at: uploads/1/2/7/5/12754304/ a3_poster_of_all.pdf. [Accessed 1 October 2020].

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    Treatments for COVID-19 could be manufactured for $1 a day or less, and distributed through mechanisms like those used for HIV, TB and malaria, reports Polly Clayden:

    First published by HIV i-Base in HTB (HIV Treatment Bulletin) on 14 April 2020.

    Polly Clayden, HIV i-Base

    If repurposed drugs, currently under investigation for COVID-19, show efficacy, they could be manufactured profitably at very low costs – according to an analysis published in the Journal of Virus Eradication
    on 8 April 2020. [1]

    As the SARS-CoV-2 pandemic grows daily, clinical trials are underway worldwide looking at potential ways to prevent new infections, treat those already infected and reduce the severity of the disease.

    Results from randomised controlled trials of repurposed drugs – ie those currently indicated for other diseases so shortening the drug discovery and development timeline – are expected between May and September of this year.

    Andrew Hill and colleagues – whose group have previously reliably predicted the minimum costs of drugs for hepatitis C and other diseases – calculated the costs of new potential treatments for COVID-19.

    The authors used established methods to make these calculations. They estimated the minimum costs of drug production by calculating the cost of active pharmaceutical ingredients (API), added to costs of excipients, formulation, packaging and a profit margin of 10%, to calculate the price of the final finished product (FFP) – the drug ready for use.

    The selected treatments were: remdesivir (previously used unsuccessfully against Ebola); favipiravir (influenza), lopinavir/ritonavir (HIV), chloroquine and hydroxychloroquine (malaria) and sofosbuvir and daclatasvir (HCV), azithromycin (pneumonia), and pirfenidone and tocilizumab (improve lung function and reduce inflammation).


    Remdesivir is given by IV infusion. A 10-day course of treatment is under investigation at a dose of 200 mg on the first day and 100 mg the following days.

    The authors estimated the cost per treatment to be approximately $9 per person – an estimated daily cost of $0.93.

    They note that costs for non-drug components associated with IV infusion were not included in this estimate:  saline, equipment (syringe, sterile water and IV lines) and staff time.


    Favipiravir is an oral treatment dosed at 600 mg twice daily. A 14-day course is being evaluated.

    The estimated cost of production for this course is $20 or $1.45 per day.

    The authors added that favipiravir was launched for sale in China in late February 2020 at a price of $231 per 14-day course.


    The standard dose of lopinavir/ritonavir is 400/100 mg oral combined pill twice daily. A 14-day course is also being evaluated.

    The estimated cost for this course is $4 or $0.28 per day.

    So far there has been no clear evidence of efficacy for lopinavir/ritonavir against COVID-19.

    Current list prices for a 14-day course range from $503 in the US to $15 in South Africa (and available through the Global Fund to low- middle-income countries for a medium of $9).

    Hydroxychloroquine and chloroquine

    These old malaria treatments (since the ’50s) were calculated at 400 mg and 155 mg daily doses for 14 days of hydroxychloroquine and chloroquine, respectively.

    The estimated costs were $1 per course or $0.08 per day and $0.3 or $0.08 per day for the respective drugs.

    Available list prices for a 14-day course of hydroxychloroquine ranged from $19 in China to $2 in India.

    For chloroquine these prices ranged from $93 in US to $0.2 in Bangladesh for a course. The authors note that the Bangladesh price was lower than their estimate and the US one might be considered an outlier (by a considerable amount as the next most expensive price for a 14-day course, in the UK, was $8).


    Used in small pilot studies with hydrochloroquine (and contradictory results) to prevent bacterial superinfection.

    A 14-day course at a dose of 500 mg per day was calculated at $1.40 or $0.10 per day.

    List prices for azithromycin range between $63 per 14-day course in the US and $5 in India and Bangladesh.


    Under evaluation in Iran for people with moderate to severe COVID-19 symptoms at a daily dosage of sofosbuvir/daclatasvir 400/600 mg.

    The estimated cost is $5 per 14-day course or $0.39 per day.

    These drugs were launched by originator manufacturers for treatment of Hepatitis C at eye-watering prices, which have fallen significantly in recent years.

    Earlier estimates of minimum price for generic production by Hill et al in 2016 were equivalent to $7.8 per 14-day course, so the new estimates represent a 6.6-fold reduction since the group’s original calculations.

    Fourteen-day list prices range from $18,610 in the US and $7 in India or $6 in Pakistan.


    A dose of 801 mg three times a day for four weeks is being evaluated.

    The estimated cost for a 4-week course is $31 or $1.09 per day.

    List prices for a 4-week course range from $9,606 in the US to $124 in Bangladesh and $100 in India for a generic version.

    The authors explained that at $100, the lowest list prices are still higher than their estimate.


    This monoclonal antibody is dosed as an IV infusion. Doses are based on weight (8 mg/kg) with a maximum single dose of 800 mg every 12 hours.

    The authors assumed an average bodyweight of 70 kg and a single dose of 560 mg.

    There were no API data available for tocilizumab – so they were unable to estimate the minimum cost of production.

    List prices for 560 mg single dose varied from $3,383 in the US to $510 in Pakistan.

    Several biosimilars are currently under development but these have yet to be approved and launched.

    Biosimilars can offer healthcare systems the potential to lower costs significantly. The UK is expected to save up to £200–300 million a year through the uptake of better-value biological medicines.


    The authors emphasised that we do not know yet which or any of these drugs will show benefit. But this analysis shows that if that was the case they all could be manufactured for very low prices.

    Repurposed drugs might be the only option to treat COVID-19 for the next 12–18 months, until effective vaccines can be developed and manufactured at scale.

    Some of the treatments are already available as generic, with prices close to the cost of manufacture for low- and middle-income countries.

    Treatments for HIV, TB and malaria are distributed worldwide by the Global Fund and PEPFAR at prices close the cost of manufacture. These prices allow generic companies to make acceptable profits. The authors recommend that a similar model of drug distribution be adopted for COVID-19.

    They made four recommendations to ensure that anyone with COVID-19, in any country, would be able to access the treatment they need:

    1. Treatments showing efficacy in well-powered clinical trials should be made available worldwide at prices close to the cost of manufacture.
    2. There should be parallel manufacture by at least three different companies for each product, sourcing their API from different countries. Production of drugs in a range of countries will protect us from disruption or shortages in individual countries.
    3. There should be no intellectual property barriers preventing mass production of these treatments worldwide. We need open ‘technology transfer’ so that the methods used to manufacture the key drugs can be shared with any country deciding to produce the drugs locally.
    4. Results and databases from all COVID-19 clinical trials should be fully accessible so others can learn from them. To speed up access to these drugs, countries could rely on recognition of the review and approval of key treatments by regulatory authorities in the US or Europe, or other stringent regulatory authorities. There may not be time for the normal times of regulatory review by all individual countries.


    The authors looked at costs of production for the main treatments currently being tested in clinical trials.  These drugs could be mass produced for $1 per day, often for a lot less, and distributed through mechanisms like those used for HIV, TB and malaria.

    Even remdesivir, the new potential treatment from Gilead, could be mass produced for $9 for a 10-day treatment course.  The cost of the saline (and other non-drug components) would be higher than the remdesivir, when given by IV infusion.

    Some of these treatments have US list prices 100 times higher than the cost of production. The Presidential-favourite untested COVID-19 candidate is over 10 times as much in US as the UK. 

    Anyone with COVID-19, in any country, should be able to access these new treatments if the prices can be kept close to production costs. 

    Previous minimum cost estimates by Hill et al have been invaluable to support price negotiations for treatments for other diseases. Among many others, MSF welcomed the COVID-19 estimates. [2] “Literally every single person on earth is susceptible to this pandemic – now is not the time for price gouging and pandemic profiteering” they wrote.

    At the moment, countries are becoming insular, competing for limited supplies of drugs, ventilators and PPE, in bidding wars, rather than engaging in a collaborative system for resources to be prioritised for areas of greatest need.  


    1. Hill et al. Minimum costs to manufacture new treatments for COVID-19. Journal of Virus Eradication. Online 9 April 2020.
    2. MSF press release. MSF response on COVID-19 drugs pricing study by Andrew Hill et al. 10 April 2020.
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    Today the Mail on Sunday published an article headlined ‘HIV treatment now costs NHS as much as breast cancer – Fears £606m annual bill for sexually transmitted disease is fuelled by flood of foreign health tourists‘.

    The only views to ‘balance’ the diatribe published in the paper and online was a short rebuttal from BHIVA  (British HIV Association) and NAT (National AIDS Trust) as well as a short statement from NHS England on how costs for HIV treatment are actually reducing:

    A spokesman for the BHIVA said: ‘In the UK, new diagnoses of HIV are now falling because of the success of testing and treatment.’

    An NHS England spokesman said the cost of HIV treatment had fallen £28 million from £634 million in 2017/18 to £606 million in 2018/19.

    A Department of Health spokesman said: ‘We’ve seen a decline of almost a third in new HIV diagnoses in the UK in recent years.

    ‘As with all other serious infectious diseases, we do not charge overseas visitors for treatment for HIV as, if left untreated, there is a significant risk to others in this country.’

    Deborah Gold, chief executive of the NAT, said: ‘The concept of health tourism for HIV treatment is an outdated myth.

    ‘It is actually a problem that we have such long average delays, usually years, between migrants’ arrival in the UK and them accessing HIV testing and care.

    ‘Universal availability of HIV treatment is a cornerstone of the response in the UK. Any suggestion this is a poor use of NHS money, or that access to treatment should be limited for anyone, is outrageous. In fact, it is evidence of the NHS at its best: saving lives and preventing ill-health.’

    UK-CAB (the UK Community Advisory Board) responded to the article via this tweet with the following statement:

    “The UK is a world leader in reducing the numbers of new HIV diagnoses and one of only six countries to have already met the UNAIDS 90-90-90 targets. This achievement would not have been possible without upscaling HIV testing and providing immediate antiretroviral treatment to all people living with HIV in the UK.

    People with HIV on effective antiretroviral treatment cannot pass the virus on to their sexual partners or to their unborn child during birth and pregnancy. The investment in free HIV treatment for everyone with HIV is fundamental to meeting the Government’s commitment to end new transmissions by 2030.

    Stigmatising information like that reported in today’s Mail on Sunday only serves to hinder the UK’s response to the HIV epidemic. Whilst we have made huge strides in reducing new diagnoses by an incredible 28% between 2015 and 2017, the numbers of people diagnosed late is still too high.

    Late diagnosis not only increases the chances of premature death but also heightens the risk of HIV being unknowingly transmitted to sexual partners. We cannot tolerate attitudes which put people off testing and finding out their HIV status.

    People living with HIV should not be pitted against other patient groups or conditions.

    Access to treatment and care for all people living with HIV ensures that individuals can live well and in good health and also stops transmission of the virus to others. Any insinuation that denying HIV treatment to those without ‘settled’ status would be a benefit to the nation’s public health or NHS budgets is nonsense.”

    Please circulate this as widely as possible.

    1 Comment

    Tell us your views

    We are the regulator for pharmacists, pharmacy technicians and registered pharmacies in Great Britain. We set standards for pharmacy professionals.

    We are consulting on guidance for pharmacist prescribers which sets out the key areas they should consider when prescribing to ensure they provide safe and effective care. Pharmacist prescribers can diagnose conditions and prescribe medicines to patients. They often work in GP practices as well as in other healthcare settings, and can also work as part of an online prescribing service.


    Read our proposals and tell us your views now


    We want to understand the impact of these proposals on patients and the public. Help us spread the word by encouraging your members to take part. To help, we have a toolkit of materials which you can download from our website.

    We look forward to hearing your feedback.

    Best wishes

    Mark Voce
    Director of Education and Standards


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    The PDA have published an in-depth report that assesses the current role and capabilities of pharmacy technicians in the UK community pharmacy sector.

    The 250-page document, which has taken 3 years to compile, highlights proposals to develop the roles of community pharmacists and pharmacy technicians, and the skill mix required to meet patients’ needs.

    The in-depth report has been developed because, in recent years as the pressure upon the NHS has been increasing, the government has been looking at ways to improve the accessibility to healthcare in the UK, to meet the needs of the public. The government has been considering the unexploited possibilities that are available through skill mix and in community pharmacy and has been placing emphasis on the greater utilisation of pharmacy technicians.

    In response to this government led initiative, this report seeks to set a sensible vision for the future development of pharmacist and pharmacy technician practice in community pharmacy and proposes ways in which this can be done.

    Before publishing the full report, in order to cover all the key topics which needed consideration, the report was broken down into discussion points, analysing key considerations and the PDA’s reasoning behind each recommendation for improvements. Now that each section has been released separately, the full report is available to read in its entirety.


    thumbnail of FINAL PT Report – 28-02-19

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    The Pharmaceutical Journal reports that the Good Law Project threaten DHSC with legal challenge over “failure to consult properly”

    From The Pharmaceutical Journal 21 FEB 2019 By Carolyn Wickware:

    The Good Law Project has warned the Department of Health and Social Care that it will start judicial review proceedings if serious shortage protocol powers are not revoked on the grounds that the consultation was “insufficient and unlawful”.

    A non-profit group has threatened the government with legal action unless it revokes new powers designed to allow pharmacists to switch patients’ medicines if there is a shortage.

    The Good Law Project has said it will start judicial review proceedings over newly implemented “serious shortage protocol” powers if the Department of Health and Social Care (DHSC) fails to remove the amendments in legislation by 25 February 2019.

    Amendments to the Human Medicines Regulation 2012, which came into force on 9 February 2019, mean the government can now issue protocols asking pharmacists to respond to a medicines shortage in one of four ways: to dispense a reduced quantity, a therapeutic equivalent, a generic equivalent or an alternative dosage form of the drug.

    Under the protocol, the pharmacist would not have to consult the patient’s GP before making the switch.

    The Good Law Project is now seeking to launch a judicial review of the amendments, partially on the grounds that the government’s initial consultation – which lasted one week on 5–12 December 2018 – was “insufficient and unlawful”.

    In a legal document sent on 19 February 2019 from the group’s lawyers to the DHSC to inform them of their intent to start the review proceedings, the Good Law Project said it was “unclear exactly who the Secretary of State consulted with and how/on what basis”.

    It added: “The failure to consult properly with organisations representing specific patient interests was unlawful.”

    Ekklesia reports:

    Jolyon Maugham QC, Director of the Good Law Project, said: “Both doctors and patients have proper concerns about their safety in the event of medicine shortages. We want the Government to withdraw the prospect of SSPs [Serious Shortage Protocols] until it has complied with its legal duties and consulted properly on their use. If the Government does not take this step, the Good Law Project will launch judicial review proceedings in the High Court.”

    Professor Tamara Hervey, Specialist Adviser to Parliament’s Health and Social Care Committee, said: “In the event of a no-deal Brexit, there would be likely to be shortages of medicines. The absence of a legal framework for imports and exports drastically affects supply chains. Stockpiling plans cannot cope for more than a few weeks. This is a serious issue for people needing a regular supply of a particular type, strength and quality of medicine.”

    Jane Hanna, Chief Executive of SUDEP Action, who is supporting the judicial review said “Patients, doctors and pharmacists are used to prescriptions and the processes surrounding them. For people with long-term conditions, like epilepsy, what is on the prescription may represent months and years of trying out the best medication schedule. Changes made to this delicate balance can for some, undo this in an instant. For epilepsy this could lead to less seizure control, impacting on quality of life (ie: losing a driving licence, affecting home and work) and significantly for some this can prove fatal.  At present if a supply of medication is made in error, lessons can be learnt because of the clarity of who signed and who supplied the prescription.

    Deborah Gold, Chief Executive of NAT (National AIDS Trust) said: “We are deeply concerned that these changes were made without proper consultation. Prescribing HIV medication is a complex process which must take account of a multitude of factors. The only person qualified to safely alter the medication prescribed to a person living with HIV is that person’s HIV consultant.”

    • The Pre Action Protocol Letter can be seen here


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    There have been bacteria on this planet for at least the last 3.5 billion years. For the entirety of our species’ existence we have relied on bacteria to aid us in breaking down food, whilst being helpless to guard against their wrath whenever we had a bacterial infection. It wasn’t until the late 19th century that more powerful microscopes lead us to understand what bacteria were and how the infections spread, in what was known at the time as ‘germ theory.’

    Understanding how bacteria made people unwell led us to greatly improve hygiene; with large government programmes to build sanitation systems, doctors started to wash their hands and utensils, and people started to drink clean water. These changes, along with other medical innovation, lead to dramatic improvements in people’s health: in 1900 one in every 125 Americans were killed every year by infection and life expectancy was just 46; by 1941, it had risen to 65 and the number of people dying annually from infections had fallen to just one in 500. It was in this year that humans finally took the upper hand in our battle to stave of infection, when a research team in Oxford demonstrated how penicillin can cure bacterial infections. By 1955 just one in every 1670 Americans were killed by infections annually (the rate has plateaued since then).

    Over the next few decades, antibiotics transformed modern medicine, not only allowing us to treat people who had bacterial infections, but also creating a safety net for other areas of medicine. Doctors can now treat other illnesses through surgery or by using drugs that have the unfortunate side effect of greatly lower immune systems (such as chemotherapy), with the knowledge that if someone picks up a bacterial infection, it can be treated.

    Sadly, however, this was not the end of the story. Every time bacteria come into contact with antibiotics there is the possibility that through a process of natural selection, they may evolve to evade the drugs, creating what is referred to as ‘superbugs’. These superbugs can often not be killed by antibiotics. They have altered their membranes so the antibiotic cannot get into their cell, developed efflux pumps to remove the antibiotic from their system or learned to make enzymes that break down the antibiotic. In the early years of antibiotic development researchers were able to come up with enough new antibiotics to replace the ones that we had lost to resistance, but this is no longer the case. There has not been a new class of antibiotic able to treat gram-negative bacteria since the 1980s. This has led to a slowly-building crisis that kills 58,000 neonates in India every year and about 1.5 million people globally. If we do not start to take robust action against superbugs, then we are looking at returning to an era where bacteria are once again a major killer for which there is no cure.

    In our recent book Superbugs: An Arms Race Against Bacteria,’ Will Hall, Jim O’Neill, and I look at the scientific, economic, and political failures that have led us to the point where antibiotics are ceasing to work, examine what will happen if we fail to act, before outlining the policy interventions that we think are required to keep us ahead in this vital arms race. In short, we need to new antibiotics to replace those lost to resistance; but more importantly we need to slow down the rise of resistance by preventing people from becoming sick, having better prescription practices when people become ill, and stop the environmental pollution from agriculture and manufacturing that sees antibiotics pumped into the environment.

    All of these problems are held back by market failures. In order to prevent the rise of resistance, public health officials often rightly try to limit the sales of new antibiotics – the more valuable a drug the stronger the impulse to protect it is likely to be. This is problematic because innovators make greater returns the more of their product they sell though their patent system, which uses price and volume as a proxy for societal value. We need a new system for rewarding antibiotic producers that incentivise new drugs without encouraging companies to oversell.

    Sanitation systems need to be improved in almost all low and many middle-income countries, so that people stop becoming sick. When we prevent illness then people will not need antibiotics. For example, at the moment, 1.7 million children die annually from diarrhoea or pneumonia, and research indicates that simply by getting people access to soap we could more than half this number. This is not just a problem in resource-constrained environments: in the US, research suggests that while 68% of people wash their hands after going to the toilet, only 5% did so thoroughly enough to remove all the bacteria on their hands.

    Finally, with diagnostics and pollution we need to find ways of getting decision makers to internalise the societal benefits that accrue from good antibiotic stewardship. Regulation or taxation should be used to stop the environmental pollution of antibiotics. Rapid diagnostics can greatly improve prescriber practices, but there is a lack of investment into this area, and often when these diagnostics exist they end up costing more than the antibiotics, and so people do not use them. This means we are ignoring the societal benefit of using diagnostics to keep resistance at bay.

    First published by the British Politics and Policy blog

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    Did you know there are a group of 7,000 UK health professionals whose employer has spent 7 years, and who knows how much money, preventing them from gaining an independent voice at work?

    What if I told you that part of this situation involves an entity, which is supposed to represent workers, that has signed an agreement with management committing to only “collective bargain” resources for their own officials and committing not to collective bargain for the employment terms of their members?

    This is what happened at Boots when the company signed an agreement with the “Boots Pharmacists Association” (BPA) in 2012 and in law this is enough to block an independent trade union, the PDA Union, from following the statutory process for recognition at that employer.

    The BPA is on the certification officer’s list of trade unions, but it is not independent. BPA was refused a certificate of independence in 2013. Part of the certification officer’s decision said: “looking at the picture as a whole that there emerges, in my judgement, a clear image of a union that has over the years been drawn into a situation in which it is indeed liable to interference by Boots… tending towards domination or control.”.

    Boots is the largest and most well-known community pharmacy business in the UK. The multi-billion pound global enterprise is a vertically integrated business profiting from both wholesale and retail sales of medicines, with much of that coming from the taxpayer via the NHS. The company has tried “everything” to block their employed pharmacists from getting independent representation and that includes the blocking agreement signed in secret with BPA at a time the company was simultaneously talking to PDA Union about statutory recognition.

    The good news is that the pharmacists have never given up and last summer six pharmacists, supported by PDA Union, applied to the Central Arbitration Committee to have the Boots-BPA agreement ended. Over 1,000 more employees pledged online to support the application, and after a further legal hearing at which the company and BPA’s joint attempt to give votes to senior managers (if they are a registered pharmacist) was overcome, a ballot is about to be held of almost 7,000 pharmacists working in Boots stores to end the blocking agreement.

    The law under which this ballot is happening has never been used before in any sector and the union must achieve 40% of those eligible to vote, to vote in support, hence their #2780pharmacists campaign hashtag.

    Ballot papers go out from 10 May and must be returned by 23 May in order to be counted. Anyone interested in supporting the PDA Union and their members can help by spreading the word about this historic trade union campaign.

    • Paul Day, National Officer, PDA Union @the_pda_union
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    The National Health Service (NHS) Act was promised in the Labour landslide election of 1945, passed into law in 1946, and the service itself launched in 1948: a non-contributory comprehensive service making all forms of medical, dental and nursing care, in hospitals or in the community, available free to the whole population, paid entirely from central government funding. I qualified from St. George’s Hospital in London four years later, and will retire from full-time clinical practice in 1988; the NHS allowed me to do my own work and refer my patients to the full range of specialist services during an entire working lifetime, without ever having to collect a fee. Several generations of British doctors have followed, with essentially the same historically novel experience.

    We have come a long way since then; there have been huge changes in the work and effectiveness of medical care, and exponential growth in medical science which will require even bigger changes in the future. If advances in medical science are to be available for all of the people, the principles on which the NHS was founded must be both restored from their present shorn condition, and extended in entirely new directions. The NHS is under attack as never before, its enemies confident that medical care can again become a commodity on the market, many of its former friends confused and capitulating. The whole world has entered a dangerous time, perhaps most dangerous of all in our own destabilizing society.

    Some Illustrative Autobiography

    All history must be selective, and therefore judgmental. Its contemporary actors, by living through one set of experiences, are denied others. Like everyone else, my assumptions derive from my own background, experience, the books that I read and the books I avoided, and my readers deserve to be warned what these were.

    I was what Americans call a ‘red diaper child’, my mother in the Labour Party, my father in the Communist Party, our home among other things a transit camp for anti-Fascist refugees from Austria, Germany and Italy. Both my parents were doctors, my father a GP recruited by the South Wales Miners’ Federation to help them in a dispute with general practitioners in Llanelli (a redleg?) who later went off to Spain as a surgeon for the International Brigades. Unlike most medical students in 1947, I knew exactly what I wanted to do before I left school; to become a general practitioner in a coal-mining community, because to me that was the highest possible ambition. Like others of that immediately post-war generation, I also felt unjustly spared. My survival was, quite possibly, accidental. Had I been born one year sooner, I might have died in the war, and therefore felt permanently bound not merely to enjoy the peace, but to win and defend it; and not just any peace, but precisely the peace that was won at that time, against Fascism and for a new era of the Common Man, as we still said in those days.

    After qualifying in 1952 and disenchanted with teaching hospitals, I sought ‘real life’ as a House Physician at Kettering General Hospital in the East Midlands, just as general practitioner (GP) surgeons in provincial hospitals were beginning to be replaced by professionals. All routine and much emergency surgery in Kettering had always been done by GPs, helped once a week by a part-time consultant who travelled 100 miles by rail from London. About six months previously, one of the GP-surgeons had been presented with a young woman with acute intestinal obstruction, a condition easily reversed by early surgery but otherwise rapidly fatal. He opened the abdomen, to find multiple obstructions by scarring from Crohn’s disease. He excised four or five segments at several points along the seven metres of small intestine, leaving the loose ends to be reconnected. Then his troubles began; which end belonged to which? Never having met this unusual condition before, he had waded into the macaroni without planning his return. In those days emergency surgery was still regarded by patients as a gamble with death. If he had confidently reconnected the tubes as best he could, praying he hadn’t created any collisions, dead ends, or inner circles, he would probably have been acclaimed whatever the outcome. Being a man of integrity, he persuaded his GP-anaesthetist colleague to keep the patient unconscious for what turned out to be four hours with a small coppice of metal clamps splayed out from the incision, telephoned the London consultant, and waited for him to come up by the next train to sort it all out. Remarkably, the patient survived. It was the last anecdote of a closing era of GP surgery; the professionals put an end to all that, and not before time.

    The General Hospital served two distinct catchment areas: on one hand, the pleasant market towns of Kettering and Wellingborough and their surrounding countryside, with deeply rooted populations of middling provincial gentlefolk and workers in farms, breweries, railways, shops and light industry; on the other, the steel manufacturing town of Corby, with a population largely imported from Glasgow. From Kettering we had people generally at an early stage of illness, with helpful, informative letters from their GPs, who often visited the wards or at least telephoned to see how their patients were getting on, and made use of the x-ray department and laboratory to investigate patients themselves before referral. From Corby we received patients with gross end-stage disease, and hastily scribbled notes from their GPs:

    Dear doctor,

    Billy  Briggs,  22 Tipslag Terrace, Corby ? acute abdomen (or chest, heart, or whatever), please admit.

    Yrs etc.

    Hearts sank when requests for admission came from Corby. They were usually about some medical crisis, often avoidable by earlier diagnosis and appropriate action. The Corby and Kettering GPs seemed to work, as their patients lived, in different worlds. It was my first introduction to the divisions of medicine corresponding to the two nations of British society.

    My boss was a bachelor who ran an Austin-Healey sports car, and endlessly complained to his junior staff about his poverty and sufferings under the NHS. I earned £250 a year looking after 20 men, 20 women and 16 children on acute medical wards, on call 24 hours a day, without right to any evenings or weekends off for six months except those personally wheedled from the boss. We differed about the NHS: he believed it would end enterprise and reward sloth, I thought it was the best thing that could have happened for the future of medicine. When he went off for the weekend he would fix me with his pale blue eye: ‘Hart: when I come back on Monday I don’t want to find the beds filled with rubbish. Old men with chronic bronchitis belong in Local Authority Part III accommodation, not this hospital.’ Some old man living alone with advanced smoker’s lung was sure to tip into pneumonia, and his GP, rightly acting as advocate, would press for admission. Though squalid dormitory geriatric accommodation did exist under Part III of the Insurance Act in what had been the Kettering workhouse, it was not bad enough to deter a queue to get in. The real choices were between solitary death at home, or a hospital bed with warm nursing, antibiotics (all requiring injection in 1952), and a good chance of recovery. That was my introduction to contradictions between what doctors were interested in and what mattered to patients.

    I asked for a reference at the end of my six months, which read as follows: ‘Dr Hart has performed his duties as a House Physician adequately during the past six months.’ At the time this seemed faint praise, but only later did I realise it conveyed the same lethal message to any experienced medical employer as Hamlet’s note on his journey with Rosencrantz and Guildenstern; my introduction to the 18th Century structure of servility and patronage endured by all doctors for some of their lives, and by many for all of their lives.

    My junior hospital career was therefore on course for self-destruct, postponed for a few more months by a consultant chest physician who persuaded me to work for him as registrar at the Watford Chest Clinic on the outskirts of London, dealing almost entirely with tuberculosis, then still a common cause of death. I was not properly trained for such respon­sibility, but the previous man in the job was an alcoholic with drug problems, and no other applicant could be found. The clinic was responsible for tuberculosis patients on the wards of a local hospital which had been a workhouse until 1948. The workhouse master and matron still lived in an elegant residence within the walls, waited on by high-grade mentally defective or so-called morally defective inmates. The barrack-complex contained geriatric and chest wards for sick people, as well as dormitory accommodation for the workhouse inmates who, though liberated by repeal of the Poor Law and advent of the Welfare State, had nowhere else to go. Men lived at one end of the building, women at the other. Most were old people without either money or relatives able to look after them, but there were also mentally or physically handicapped younger people, and several young homeless families. Young or old, married, widowed, or single, males over seven years of age were separated from females except at strictly enforced visiting times.  The work was interesting but uncomfortable, not because of the Dickensian surroundings but because I knew I was under-trained. Sink or swim, I learned as I went along; I swam, patients sank.

    Just before the lethal reference could catch up with me, I was saved and diverted prematurely into general practice in the wrong place. At the end of 1952 I was chatting to an old Irish GP, Dr Henry Blaker, in a corner dairy in North Kensington. He had retired from a lifetime of work for the Indian Medical Service in Calcutta, to buy a practice from an old colleague, Dr Sweeney, in the slums of North Kensington, with about 2,000 registered patients. His sight was failing from cataracts and he was no longer able to drive, doing his home visits on foot or on the underground. On hearing I was a Cambridge graduate, a fact which impressed him more than me, he asked me to join him as an equal partner starting tomorrow. Only later did I realize how exceptionally just he was; then even more than now entry into general practice, or into almost any other medical job, was difficult, and many established GPs took full advantage of this to exploit their younger colleagues with grossly unequal partnership contracts. Postgraduate experience before starting practice was still an optional extra generally reserved for entry into ‘practices of the better type’. North Kensington was Corby not Kettering country, and even the scanty hospital experience I had seemed much more than my local colleagues expected. Under personal pressures which are irrelevant here, I took the job.

    Urban Industrial General Practice in the 1950s

    The surgery was in what had been a large corner pub in Clarendon Road, off Holland Park. The area is now gentrified beyond recognition, full of media persons and croupiers at the Stock Exchange, but then it was the edge of one of the worst slums in London, stretching from the bottom of Notting Hill in the south, to Harrow Road and the Grand Union Canal in the north. The pub was all elaborately decorated plaster cornices, frosted glass, and engraved mirrors still advertising various ales, stouts, porters and whiskys. Dr Blaker’s surgery was in the saloon bar, the waiting room in a narrow adjoining room previously used for off-licence sales. It was nearly always full of people waiting to get in, often with more standing in the street, sometimes in the rain. Patients entered the consulting room at one corner, stepped down from the raised area previously behind the bar counter, and sat in front of an enormous oak desk covered with wooden boxes, books, urine test glassware, and unopened copies of the British Medical Journal. When I eventually sorted this out, I found one of the boxes contained a full set of equipment for post-mortem examination, with bone saws and knives of every size and description. A small working area of desk was cleared in front of the doctor’s swivel chair. Behind him was a threadbare printed fabric screen, folded and apparently rarely used. Behind this again was a low divan couch covered in American cloth and stuffed with horsehair, much of it bursting out through ulcers and abrasions acquired in forty or fifty years of combat. On the wall to his right was a large white semicircular washbasin with a single brass cold water tap, an amenity added a few months previously; Dr Blaker warned me not to pee in it, as some previous locums had done. Next to this was a metal stand with a china bowl and ewer, now redundant but, like the junk on the desk, kept on standby in case the 19th Century returned, a not unlikely event to any thoughtful observer. This time-warped impression was strengthened by a glass fronted cup­board set in the wall of the waiting room, still full of dusty medicine bottles waiting to be collected by patients whose names could still just be made out on the elegantly scripted labels. Apparently Dr Sweeney had done his own dispensing, and when the practice finally gave up competing with the local pharmacy this cupboard was simply locked and left as it stood!

    There was no receptionist, so patients’ medical records, the small pocket envelopes devised in 1916 for the Lloyd George Act and still used by nine out of ten English GPs, were housed to the left of the great oak desk in a nest of wooden drawers. Virtually the only entries ever made were of medicines prescribed, but occasionally there would be a brief diagnosis (‘asthma’, ‘fractured femur’, ‘neurotic’) without any of the evidence on which the diagnosis was based. Useful clinical information, if any, was confined to hospital correspondence, folded and pushed into the record envelope in a more or less randomly ordered and increasingly tattered bundle.

    Twenty to thirty patients came each morning, about the same number in the evening, and between these two sessions I was supposed to fit in about 15 house calls. There were nearly always two or three visits left to do after the evening session, together with any late calls. I would finish by 7.30 if I was lucky, by 9.00 if I was not. I did all the night work for that first year.

    One year to the day after I started, without warning or discussion, I found a note from Dr Blaker on the desk to say he had retired and the practice was mine. I took a partner of my own age and we built up the practice to about 3,000 when I left in 1957 to resume my interrupted hospital train­ing, this time on the children’s wards at Hammersmith Hospital. Workload steadily fell, reduced by good practice organization, employing a receptionist and dealing with the underlying causes of such clinical problems as were soluble, rather than sidestepping them with symptomatic treatment. When I left the practice, we often saw only ten or twelve patients at each session, despite a much larger population at risk.

    South Wales in the 1960s

    After another three years of junior hospital posts and some experience of epidemiological research, first with Richard Doll and later with Archie Cochrane, in 1961 I finally reached my original goal, a single-handed general practice in a small coal-mining community in the Afan Valley in South Wales. The daily consulting rate in Glyncorrwg was roughly the same as when I started in London: 20 to 30 patients at the morning session, the same in the evening, 12 to 15 home visits, for about the same number of people at risk. The time available for each consultation was 5 or 6 minutes, slightly more than was found in a large study of practices in Aberdeen ten years later, (Buchan,   I.C.,   Richardson,  I.M.,   ‘Time study  of consultations in general practice’. Scottish Health Studies no. 27. Edinburgh: Scottish Home & Health Department, 1973.)  but less than the average 8.25 minutes found in the most recent survey of GP workload in 1986. (‘Survey   of  GPs’  workload’,  British  Medical  Journal  1987,  294:1241.) Unlike my London experience, improved practice organization had little effect on workload; the reserve of unmet need seemed inexhaustible.

    The squalid conditions of industrial working-class practice I met, first in London and later in South Wales, were incompatible with the standards of clinical medicine taught in medical schools, denying self-respect and limiting the imaginations of GP and patient alike. They were essentially the same as those pilloried by Collings(Collings, J.S.,  ‘General practice in England  today’,  Lancet 1950,i:555-85) in his classic report in 1950 on British general practice. Thirty-four years later Eric Wilkes, Professor of general practice in Sheffield, described the same squalor in 1984 in a despairing paper entitled ‘Is good general practice possible?’ (Wilkes, E., ‘Is good  general  practice possible?’,  British Medical Journal 1984; 289:85-6.) . British general practice has changed in my lifetime, but very unevenly and very incompletely. It has changed least of all in the old areas of heavy industry, where the real wealth of this country was originally made, and where poverty and unemployment are now most miserably endured.

    General Practitioner and Referred Care

    Having worked a lifetime in general practice, that is the point from which I see the NHS as a whole, and the people it serves; a close underview from where the action begins, rather than an overview from hospital specialism where some of it ends, or from the outer space of a university library.

    To an extent unique in Western Europe and North America, the British medical profession is and has for well over 50 years been divided into two easily defined groups, with little overlap: GPs responsible for registered lists of patients, who care for them only in their own homes and communities; and consultant specialists responsible for all hospital work, assisted by young doctors in training (most of whom later become GPs), who only see patients on referral from GPs. GPs therefore remain generalists, whose real specialized skills are based on familiarity with a specific local population. All other levels of the NHS rest on general practice; the quality, efficiency, and effectiveness of specialists are limited not only by the resources made available to them by the State, but also by the quality and completeness of GP care.

    The National Health Service created, and was designed to create, a dramatic improvement in both the extent and the quality of care by specialists in hospitals. It also suddenly extended GP care from the minority of male manual workers covered by the old Lloyd George Insurance Act, to the entire population. It vastly increased the accessibility of general practice but did nothing, and was not designed to do any­thing, to improve its quality. Clinical medicine in British general practice did improve between 1948 and 1967 (the first important structural reform of NHS general practice), but not at anything like its pace of improvement in hospital care. Nor were improvements selective for those social and geographical areas most in need of them. In general, the quality of all medical care, and particularly of GP care, was lowest where the needs of the population were highest; what I later described as the Inverse Care Law. Neighbourhoods with the worst health inherited the worst traditions, expectations and resources, and were least competitive in the market for well-trained, innovative young doctors. General practice remains an area of relatively poor perform­ance, falling short even of its traditional task of meeting the immediate demands of patients for care of symptomatic illness; it is better, much better, than it was, but still far below what it should be. General practice is even now only beginning to accept its huge future potential for effective health conservation, through which its impact on the health of the general population could be greater than anything possible through specialist care in hospitals.

    ‘The Health Service is Hospitals

    Most politicians, media persons, or members of the general public, asked for their mental picture of what is central, important, and effective in the NHS, will describe something going on in a hospital. For most people, hospitals appear to be virtually the only source of effective treatment for life-threatening or seriously disabling conditions; the job of GPs is to sort out major from minor conditions, referring major ones to specialists in hospitals, dealing with minor ones them­selves. Planned government investment in hospitals through­out the land, in their staff, equipment, and buildings, with demand from the whole population limited only by the process of GP referral, was the great leap forward which made the NHS such a huge public success.

    Until 1967, there was virtually no investment at all in general practitioner services, except what GPs themselves were prepared to spend from their own pockets. The 1966 Package Deal (also known as the GP Charter) brought some indirect public investment in the form of 70% reimbursement of wages to encourage employment of office and nursing staff, 100% reimbursement of rent for suitable buildings, and incentive payments for group practice. Eventually this almost wiped out two common features of industrial general practice; the seedy front-parlour surgery in the GP’s own home, and the squalid shop on the high street with a half-painted glass front, staffed only by a harassed GP’s wife. It reduced the proportion of GPs working single-handed from 43% in 1952, to only 14% by 1980. This did not always improve access for patients, but did encourage sharing of staff and equipment, and placed some limit on the idiosyncratic behaviour of GPs. Even this investment was not fully taken up. GPs are now entitled to claim 70% reimbursement of office and nursing staff wages up to two Whole-Time-Equivalent (WTE) staff for each GP. For the past ten years the actual number employed has stuck around 1.1-1.2 WTE per GP, and only about 15% employ their full entitlement; (Hart’ J T , ‘Practice nurses: an under-used resource’, British Medical ‘ Journal, 1986, 290:1162-3.)most GPs evidently don’t think they need a larger team.

    The most important feature of public investment in general practice, however, is that it is neither planned nor plannable. Though GPs now accept some public investment, they are not publicly accountable, except in the narrow and negative sense that they are answerable for complaints. General practice has for seldom-considered historical reasons become a public service privately administered. GPs are independent contractors with government, to provide a public service on their own initiative, with little public control, all of it negative. Even within the narrow limits set by the maximum resources available through the present GP contract, quality of service depends on autonomous decisions by GPs.

    Imagine the state of our national road network, if it were financed by a multitude of turnpikes, the quality of each stretch depending on local owners and local expectations; a few miles of motorway, suddenly replaced by a three-lane A road, then a narrow, rutted, unpaved lane, then another mile of motorway, and so on, each depending on the interest and integrity of its owner. It would be an inherently corrupt situation, since whatever he spent on his stretch of road he would be unable to spend on himself or his family. It would be cheap, and occasionally charming, but ineffective as a transport system. For the same reasons, general practice is  also cheap, occasionally charming, and, if its task is so far as possible to maintain the health of the whole population, ineffective.

    1935-1970: An Age of Optimism

    Aneurin Bevan‘s bold nationalization and expansion of hospitals coincided with a worldwide wave of optimism about the effectiveness of medical science, and the feasibility of delivering it to all of the people.

    The 35 years from the discovery of sulphonamides in 1935, the first antibiotics suitable for mass use by non-specialist doctors, were a golden age of uncritical faith in the social value of applied medical science. This began to collapse around 1970, with a general mood of radical criticism among young people, together with the beginnings of doubt and retreat from the commitments of the Welfare State and the social contract built on the double victory of 1945, the war and the Labour landslide election. Criticism of medical activity at all levels, focused particularly on high technology care in hospitals, has persisted ever since, both from ‘Left’ and from ‘Right’ perspectives.

    Source of figures: Derived from Registrar General’s Decennial Supplement, England & Wales 1931, and Registrar General’s Statistical Review of England & Wales, various years. Figures reproduced from ‘Disorders which shorten life’, OHE 1966, by kind permission of the Office of Health Economics, London.

    Fig 1-1  Maternal  mortality,   death  rate 1860-1964, England and Wales.

    Maternal Mortality 1860-1964

    Note: (1) Ten year averages 1861 to 1890, five year averages 1891 to 1930, annual rates 1931 to 1964. (2) Logarithmic scale.

    Fig. 1.2 Pneumonia, death rate per million males living, by age, 1861-1964, England and Wales.

    Pneumonia death rates 1861-1964

    Note:   (1)   Females rates are similar and in order to facilitate graphic presentation are not shown.

    Ten year averages 1861 to 1930, annual rates 1931 to 1964. Logarithmic scale.

    There is little doubt about the starting date for this era, which more than most historic turning points derived from precise technical as well as less easily defined social and political change. Dramatic effects on valid indicators of disease susceptible to sulphonamide treatment are shown in Fig. 1.1 for death-rates of women in childbirth (maternal mortality), (Loudon, I.,  ‘Puerperal fever, the streptococcus, the sulphonamides,  911-1945’,   British   Medical  Journal   1987;   295:485-490) and in Fig. 1.2 for death-rates from pneumonia in young men.

    Clearly something dramatic happened in the mid-1930s to two common causes of premature death, but it is important to remember that this advance in effective treatment occurred against a background of steady improvement in death rates from all causes, which seems to have started around 1870 (Fig. 1.3), with full industrialization of the British economy, and the beginning of intensive rather than extensive exploita­tion of industrial workers. This improvement in health was probably caused mainly by improved nutrition, education, and housing, and by reduced occupational risks (in that order of importance), all of which have bigger effects on health than personal medical care.(McKeown, T., The role of medicine, Oxford: Blackwell, 1979.)

    Fig 1.3 Death rates per million living from all  causes,  by age,   1841-1964, England and Wales.

    Death rates 1841-1964
    Note:   (1)   Five year averages 1841 to 1960, annual rates 1961 to 1964. (2)   Logarithmic scale.

     Fig. 1.4  Diphtheria. Child death rates per million; England and Wales 1931-60.

    Diptheria deaths in children 1931-60

    Source: Registrar General’s Statistical Review, Part I. Figure repro­duced from ‘The lives of our children: a study in childhood mortality’, OHE 1962, by kind permission of the Office of Health Economics, London.

    It is equally important to remember that advances in medical science only lead to improvements in health to the extent that they are generally applied; sulphonamides did not save women in childbirth or young men with pneumonia unless doctors prescribed them. On the other hand, sulphonamides were toxic in high dosage, and a lot of damage was done by doctors who used them inappropriately or carelessly. This is obvious, but seems to have been ignored both by pre-war Ministers of Health and by practising doctors. Fig. 1.4 shows deaths of children from diphtheria from 1931 to 1961. Clearly there was a dramatic improvement in 1941; an effective diphtheria vaccine had been commercially available from about 1922, but was not applied as an organized programme for mass immunization to the whole child popula­tion until nearly 20 years later.

    The NHS is a social construct, whose advance or decline depends on social ideas and competing social pressures. Advances in medical science like the discovery of diphtheria vaccine are not automatically applied to the general popula­tion. The age of optimism in medicine was just one part of a general period of post-war liberal illusion, which denied the value or necessity of social struggle, and imagined that a classless society could be painlessly achieved by ‘levelling up’ in a consumerist, capitalist and corporate nation. That kind of liberal optimism died in Vietnam. It has been replaced by strategies of retreat, the subject of the next chapter.

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    The excellent Clare Gerada, Chair of the Royal College of GPs is calling for a brave and honest debate about rationing medicine.  According to GP magasine two thirds of GPs think that the NHS should stop providing free prescriptions for drugs that are available over the counter.  Generally stuff like Calpol which you can buy without a prescription is cheap, less than the £7.65 prescription charge we have to pay in England.  So it seems unlikely that requests for this stuff are coming from the people who have to pay charges.  Only a small minority of prescriptions attract a charge  – and none at all in Scotland, Wales or Northern Ireland.  So some of these requests may be coming from people who really have trouble finding small sums for medication.

    Honest debate about rationing medicine

    Child taking medicine

    Gordon Brown was talking about abolishing prescription charges in England in 2008, and we investigated the options.  Prescription charges were imposed in 1952 as a rather primitive form of rationing.  Apart from the free prescriptions for the poor, the old and the young there is a list of medical conditions which entitle a patient to free prescriptions – because in 1968 when prescriptions were reintroduced by the Wilson government there was life saving long term medication for those conditions.  The list hasn’t been revised since.   As the charges tend to deter people just above the level which qualifies them for free prescriptions from taking all their medication there is a downside.  Some of those people will end up in hospital because they don’t take their medication.

    Rationing healthcare is universal and inevitable.  The only question is how it should be done. Asking people to pay at the time they need treatment is agreed to be the worst possible way of doing it.

    Dr Gerada has often called for decisions about rationing to be made by politicians, not doctors.  We haven’t seen a rush of politicians stepping up to make proposals about what should be rationed or how.  The NHS reforms introduced by this government are designed to insulate politicians as far as possible from unpleasant decisions of this kind.  In reality it’s probably better for most of these decisions to be made in the consulting room than in Whitehall.  The introduction of Clinical Commissioning Groups does seem to have had beneficial effects in many areas, because it’s forcing GPs to look at each other’s practise and see where money could be saved.

    Perhaps the price doctors should ask in return for taking responsibility for rationing decision is that prescription charges should be abolished in England. Then the discussions in the consulting room need not be complicated by considerations about charges.

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