Peter Lapsley: From minor to major

Peter Lapsley It is good to be able to report good news from time to time, doubly so when it is two pieces of good news rolled into one.  The government’s decision not to proceed with Automatic Generic Substitution (AGS) is a case in point.

From the patients’ and carers’ perspective, AGS would have been potentially disastrous, not least for those who care for children with severe eczema. The bases used for emollients and topical corticosteroids vary considerably. Because everybody’s skin is different and because different people react differently to different treatments, it is essential that the widest possible range of topical treatments for skin diseases should be available on prescription to enable people to find those that suit them best. It goes almost without saying that they should then be prescribed those treatments. One of the main arguments against AGS was that it posed a very serious threat to that principle and, if they were aware of that threat, the patients and carers affected would be delighted that it had been kicked into touch.

What is good news also, though, is that the government listened carefully to the arguments put to them during the consultation process and responded to them positively. It might be supposed that that is what always happens, but it has not been in the past. Patient advocates and others have become wary of the ‘consultations’ associated with health policy development which have seemed all too often to be little more than shams. The clear impression has been that the government reached a decision and then “consulted” people about it but took little or no notice of views that conflicted with their foregone conclusion. This consultation was different and genuine, and that is to be welcomed warmly.

It is to be hoped that similar notice will be taken of the arguments repeatedly put to the government for ditching the term ‘minor ailments’, which has frequently been used to encompass acne and eczema. It is a gross over-simplification which severely disadvantages those with moderate or severe skin diseases.

In policy papers, the influential think tank, Demos, and the Proprietary Association of Great Britain (PAGB), which represents companies providing over-the-counter treatments, have both recently classified acne and eczema as ‘minor ailments’ which can be self-managed with pharmacist assistance. In many people – indeed, in a majority of cases – that may be an accurate description, but in a significant number it most certainly is not. Anyone who has seen children with moderate or severe eczema, or people with severe, scarring acne, must have been struck by how disfiguring, distressing and intractable those conditions can be. In such cases, the skin disease often eclipses all other long-term conditions the patient may have, becoming a very serious preoccupation. I speak from personal experience. Like many people, I have several long-term conditions including angina, Type 2 diabetes and psoriasis. If I could be rid of just one of those three, it would be the psoriasis I would rid myself of without hesitation.

It could be argued that a pharmacist seeing a case of severe acne or eczema would immediately refer the patient to the GP. But there is a complicating factor. Typically, GPs receive only about six days’ training in dermatology in the whole of their medical training, a period I have heard referred to as “the dermaholiday.” Practice nurses and pharmacists receive – none (in the interests of clarity, damn all, zero, zilch) which is an atrocious state of affairs. It is exacerbated by the complete absence of any mention of skin diseases in the Quality and Outcomes Framework and by the consequent absence of any financial incentive for GPs to improve the quality of the dermatology services they should provide. None of that bodes well for the patient with moderate or severe acne of eczema, who may or may not be referred to the GP, sooner or later, and whose GP may well know little more about skin diseases and their treatment than the referring pharmacist.

All this has been explained to the UK Department of Health clearly and repeatedly. Now in listening mode, it is to be hoped that they will take note of the problem and seek a solution to it. Their positive response to the arguments against AGS suggests that there might just be light at the end of this tunnel, too.

Declaration of interests:

The author is patient editor of the BMJ. He was chief executive of the Skin Care Campaign for ten years until March 2007, is an honorary member of the British Association of Dermatologists, an honorary member and chair of trustees of the Primary Care Dermatology Society, and chair of the Oversight committee for the all party parliamentary group on skin.