Editorials

Viagra and rationing

Let the sunlight in, let the people speak

Editorial p 759 News p 765 Medicine and the media p   824

The inability of Britain's government to come to terms with rationing is exposed by this week's "interim guidance" that doctors should not prescribe sildenafil (Viagra) (pp 000, 000). ^{1 2} The government should use this opportunity to lead the debate that Britain needs on what will be provided on the NHS, who will decide, and how.

The fiction of the NHS, encouraged by this government and the last, is that the NHS can provide a comprehensive, high quality service that is free at the point of delivery and covers everybody. The reality, well recognised by most of those working in the service, is that health systems cannot meet all four principles.³ Something has to give. The United States has never had universal coverage. Britain has had continuing slippage in comprehensiveness, quality, and free access at the point of delivery, and now comprehensiveness is abandoned to a blare of trumpets.

"Media coverage of this drug to date," said Frank Dobson, secretary of state for health (recognising an opportunity to try and pin the blame elsewhere), "has created expectations that could prove a serious drain on the funds of the NHS. If this were to happen, other patients could be denied the treatment they need. I cannot allow this to happen." The reality is that patients are denied the treatment they need every day of the week. What's more, coming through the pipeline are a series of "lifestyle" drugs that will be attractive to those who want to be thinner or to soup up their slowing brains. Recognising that the founding principles of the NHS cannot be maintained, many would opt for abandoning comprehensiveness rather than universal coverage, quality, and free access at the point of delivery.

Mr Dobson might thus find considerable support for the painful decisions that have to be made. What is unacceptable is that these decisions are made piecemeal, on the hoof, behind closed doors, according to unknown criteria. We need a comprehensive, transparent, continuing debate that is based on evidence and values. Almost certainly Britain needs an institutionperhaps a version of the Royal College of Physicians' National Council for Health Care Priorities⁴that can hold the debate. There will be no end to the debate and no neat resolution, but the process will be of vital and continuing importance.

Instead, Mr Dobson is seeking "further expert advice" and "discussions with the manufacturer." No doubt he will try to bully the manufacturer into reducing the price. Good luck. But this won't solve the problem. Nor will "expert advice." There are no technical fixes for rationing. No expert can trade a man's impotence against a couple's infertility against adequate care for psychogeriatric patients against chemotherapy for childhood cancer. These trade offs depend on the values of our society, the agreed purposes of the NHS, and many other issues laid out in the agenda for the rationing debate published by the Rationing Agenda Group in the BMJ.⁵ The government has never taken up the agenda offered by the Rationing Agenda group, but now would be a good time to do so. The government cannot be blamed for failing to provide, but it can be blamed for obscuring and avoiding the debate.

Will Gaylin, president of the Hastings Centre, bemoaned that in the United States that "What could have been a wide open, far ranging public debate about the deeper issues of health careour attitudes toward life and death, the goals of medicine, the meaning of "health," suffering versus survival, who shall live and who shall die (and who shall decide)has been supplanted by relatively narrow quibbles over policy."⁶ Britain should accept George Eliot's invitation and take up the "the labour of choice." And the government must lead.