Last year I was at a clinical update day for GPs and one of the topics covered was the current guidance for anti-platelet treatment. Clopidogrel has now replaced aspirin in several areas. For instance, it is now the anti-platelet of choice after stroke. The king is dead, long live the king.
I’ve no problem with that – but I was a little shocked to discover that the evidence for its superiority has been known since 1996. Seventeen years? I know it takes a while but this seems a little beyond even the usual delay from research into practice. The key factor that has now changed is that clopidogrel is out of license – so it is a darn sight cheaper than it was. It was purely a cost-effectiveness decision to keep aspirin. Actually, even in terms of pure effectiveness, the difference between clopidogrel and aspirin is quite small – and the confidence intervals cross so it may not be real in any case. But clopidogrel does appear to have the edge and hence the recent change.
(Just as an aside. Do you say CLOPPY-DOG-rel or CLOH-pidogrel? I’m fairly sure the latter is ‘right’ but the first always sounds more fun and less Pharma.)
It is clear that this was a case of rationing. I don’t have a problem with that either – it’s hard to envisage a sustainable health service that doesn’t ration in some form, at some point. However, the public health approach can jar at the individual level. For instance, and this is just a little thought, if you had a bit of spare money would you have been prepared to spend it on clopidogrel rather than aspirin? An upgrade if you like. If I’d had a stroke I’d be pretty enthusiastic about doing what I can to reduce my chance of another. Should people have the option? Or perhaps it’s the price we have to pay for the NHS – we won’t always get access to the absolutely leading edge of healthcare but all of us, without exception, will receive something that is pretty darn good. It’s a deeply political argument and you can apply it to all areas of medicine. Heck, you can have the same debate about schooling.
We shouldn’t be under any illusions though, the NHS doesn’t provide perfect treatment every time. It never could. The clear downside of allowing any sort of ‘top-up care’ is that it will worsen health inequalities and encourage a two-tier system. That is, in my view, highly undesirable and I’d pick the NHS above other healthcare systems because I value the total inclusion it provides. Yet, when sat with a patient it’s awkward as we’ve withheld information from people who’ve had strokes about the best possible treatment. The real differences may not have been great but it still feels a little uncomfortable.Read More