To cross the Rubicon is to pass a point of no return, and the NHS is fast approaching one. Last November, the Medicines and Healthcare products Regulatory Agency (MHRA) granted an additional licence for a type-2 diabetes injection, Mounjaro, to be used in obesity management. The National Institute for Health and Care Excellence (Nice) is considering making it available on the NHS.
Mounjaro, like its sister products Wegovy and Saxenda, suppresses appetite and – alongside diet and exercise support – can help users lose as much as 20-25 per cent of their starting weight over the course of a year. Raised blood pressure and impaired sugar control improve in tandem. These changes are generally maintained for the duration of treatment but are typically reversed following cessation. Mounjaro’s sister products are currently available for obesity only through specialist weight management services. Mounjaro’s manufacturers, Eli Lilly, argue it’s suitable for prescribing in primary care. Patients will be able to ring up, book an appointment with their GP and come away with a prescription that claims to help solve the weight management battles that most will have been unsuccessfully waging for years.
Yet far from being a good news story, Mounjaro illustrates everything the Labour government must tackle if it is to have any chance of a sustainable NHS. There are three problems. First is the way new medications are evaluated. The MHRA is concerned with one question: does the drug do what it claims to do reasonably safely? If the answer is yes, it gets a licence. Nice’s question is different: does the treatment represent value for money? To do that, Nice attempts to model what gains can be expected and at what cost. If that is below an arbitrary ceiling, it gives the drug the green light. NHS commissioners are then obliged to make it available within three months.
Yet, remarkably, no one – not the MHRA, Nice, or any other body – has to take account of the wider picture. If Mounjaro is rolled out for use in primary care, it will break the NHS. There simply isn’t the capacity in general practice to accommodate the (literally) millions of patients who would seek it, nor is there the budget to meet its cost (upwards of £100 per patient per month for the injections, let alone the staff time to initiate and monitor them). In piling ever more obligations on the NHS, Nice has no regard for budgetary implications, nor the capacity of doctors and nurses’ finite working weeks.
The second problem is that both Nice and the MHRA are in the grip of an epidemic of scientific illiteracy. Just because a medication changes numbers (weight, blood pressure, glucose control) doesn’t mean it does patients any good. History is replete with examples of drugs that changed surrogate markers but didn’t improve morbidity or mortality, and in some cases worsened outcomes. Pharmaceutical companies used to have to conduct trials to show their products achieve meaningful results, which is expensive and time-consuming. Now, simply demonstrating effects on surrogate markers is deemed to suffice. Among the countless prescriptions being dispensed today, no one knows how many are clinically effective and how many might be causing unsuspected harm.
Thirdly, the MHRA and Nice are operating in a silo, divorced from any cross-governmental strategy for public health. Should we spend ever increasing resources trying to counter the ill-health being driven by industries such as food, alcohol and tobacco, and by the socioeconomic conditions we are currently allowing to prevail? Or is a completely different approach long overdue?
The issue of Mounjaro represents an inflection point for Wes Streeting. If he allows business as usual, it will fatally undermine his hopes for NHS restoration. But using it as an opportunity for radical change might just turn the NHS away from the banks of the Rubicon, and set it on a healthier, more sustainable course.
[See also: The menopause industry is a murky area of women’s healthcare]
