'FLU AND RELENZA

The UK Government has just decided to accept the recommendations of the National Institute for Clinical Excellence to not allow NHS funded presciptions for this drug which is the first anti-viral drug that is effective against the 'flu. Why? Is this a good decision and do we, as a practice, support it?

The Background. 'Flu is a viral illness and as such ordinary antibiotics are totally ineffective against it though they may be required if a susceptible individual goes on to develop a bacterial chest infection as a consequence. Most of the time 'flu, although it causes unpleasant symptoms like fever, muscle-pains, headache, lethargy etc. is not dangerous to healthy adults. It can cause problems in the frail, the elderly and those with chronic health problems like asthma, diabetes, chronic bronchitis or heart disease but people in these groups should be receiving a 'flu jab every year (See Page2.html or The Chief Medical Officer's Letter to doctors of August 1998 [in Adobe Acrobat format] for a fuller list of eligible categories). Recently research into anti-viral agents against the 'flu-virus itself has started to bear fruit and the first such drug on the market in the UK is called Relenza (zanamivir). You will probably know that the new advisory body on the effectiveness of treatments, NICE (National Institute for Clinical Excellence) has advised the Secretary of State for Health that research at present available does not justify making this drug available on the NHS.

The Arguments.

• Effectiveness. In healthy adults it does reduce the duration of 'flu symptoms fractionally (from 6 days to 5). However, it was always unlikely that it would be approved for this group. Disappointingly it seems to offer little protection from serious complications in the vulnerable groups - though NICE has asked for further research in this area. At present there is no substitute for the 'flu jab.
• Cost - both in monetary terms (upwards of £9.9 million > £15 million in an epidemic year) and resources - each prescription requiring a doctor's appointment when many would normally self-treat. This would have an adverse effect on the delivery of healthcare in other areas.
• Freedom to receive effective drugs. No-one is suggesting that the drug is totally ineffective so as with Viagra a possible benefit is being withheld from patients and unlike with Viagra the GP cannot provide a private prescription at present without breaching his/her contract. Some might see this as an infringement of their civil rights.

Relenza and Viagra are focussing our minds on to what the NHS should and should not provide. There has always been rationing in the NHS - operations, kidney machines, transplants, ITU beds, etc. - and access has been restricted by waiting list, by age, by co-existing illness. In many ways this latter type of rationing is less now than in the past. Patients who would previously been thought unsuitable for kidney machines or coronary care beds now routinely get them. When I worked in hospital 20 years ago an older person over 75 would never be admitted to coronary care, now they often are. Similarly patients with kidney failure who had other serious chronic illnesses would be unlikely to get access to haemodialysis - now that is not the case and diabetics make up a substantial sub-group of dialysis patients. What is relatively new is the extension of the rationing concept into Primary Care. However the last government started the ball rolling on this with the limited list although that mainly weeded out ineffective drugs and those for which a much cheaper alternative existed. With both Viagra and Relenza no-one is arguing that they are ineffective although Relenza is disappointing so far, nor is there really a cheaper alternative. What they both have in common is that they are relatively expensive (though in the same region of cost as most new drugs) but also, and this is possibly crucial to the government's action, have the potential to stoke up an unpredictable and possibly very high level of demand if unrestricted and are also not central to the business of the NHS.

What do you think - mail RELENZA@whinfield.co.uk 

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