Equity in the new NHS: hard lessons from implementing a local healthcare policy on donepezil

doi:10.1136/bmj.323.7306.222

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Yvonne Doyle, director of public health (yvonne.doyle@mswha.sthames.nhs.uk)

Merton, Sutton and Wandsworth Health Authority, London

Correspondence to: The Wilson, Mitcham, Surrey CR4 4TP

Accepted 4 June 2001

Restricting access to expensive drugs that have modest benefits often leads to public protest. One such drug is donepezil, which is recommended for treating mild to moderate Alzheimer's dementia. Initial enthusiasm for the drug was dampened by revelations about the select nature of the study population, sharp marketing practices, and the unsatisfactory process during licensing.1 Nevertheless, somehow the public debate shifted to the problems of funding the drug. The National Institute for Clinical Excellence issued guidance on the drug early in 2001, stating that it has limited benefit in certain carefully assessed patients.2

Summary points

Debate is needed about the merit of open access to expensive treatments for many people to identify the few who gain marginal benefit

An evidence based approach can conflict with perceptions of fair access by patients and carers

This conflict poses a challenge to independent local advisory forums proposed under the NHS plan

Since blanket bans on access to treatments are legally indefensible, the process of decision making must be reasonable and transparent

Inequity of access within a district

Merton, Sutton and Wandsworth Health Authority devised its first policy on donepezil in 1997 in response to national and local consumer interest in the treatment. Having assessed the evidence in various prescribing and effectiveness groups, the authority concluded that the drug's benefits were insufficient to warrant funding. The majority of consultants agreed with the decision, although there was some dissent, particularly among doctors treating elderly patients. The drug was not placed in the formularies of any of the authority's hospitals and was consequently not prescribed in secondary care. The appearance of guidance from the Standing Medical Advisory Committee in 19983 did not change clinical opinion or the policy.

Between 1997 and 2000 various inconsistencies became apparent. Firstly, some general practitioners were prescribing the drug in primary care. At any time since …