The safe sex messenger, VIEWS & REVIEWS p 1002 If it was breast (Not) warts and all cancer, there would doubtless be an PERSONAL VIEW Phil Hammond industry supported march on Downing ou’d be mad not to pro- Immunisation is most illuminating. “If the vac- Street, but the tect your daughter against cines were offered at similar prices, then the genital warts lobby genital warts if you can committee recommended choosing the quad- is largely under afford to.” So advised rivalent vaccine, which would protect against BARRY BATCHELOR/PA ARCHIVE/PA PHOTOS ARCHIVE/PA BATCHELOR/PA BARRY cover Peter Greenhouse, a sex- cervical cancer and genital warts,” said a com- “Yual health consultant in Bristol, when I asked mittee statement (www.advisorybodies.doh.gov. in the programme getting Cervarix and most him which human papillomavirus vaccine uk/jcvi/HPV_JCVI_report_18_07_2008.pdf). outside it getting Gardasil. This clearly has the I should choose for my daughter. The NHS The British National Formulary gives exactly potential to undermine the programme (or at vaccination programme may have opted for the same price (£80.50 for each of three injec- least it would if anyone was brave enough to the bivalent vaccine (Cervarix) to concentrate tions) for the two vaccines, so GlaxoSmithKline shout about genital warts). resources on preventing cervical cancer, but (GSK), which makes Cervarix, offered a dis- For any licensed treatment, the public (and every doctor I’ve spoken to has chosen the count to undercut Gardasil’s manufacturer, NHS staff) need quick and easy access to unbi- quadrivalent vaccine (Gardasil) for their own Sanofi Pasteur. ased data on efficacy and safety, updated as daughters (and the odd son, though of course I have no issue with this. New drugs are ludi- it emerges. The NHS website would seem to this is off licence). crously expensive, and the NHS deserves credit be a logical gateway for this, but it currently Genital warts are common (100 000 new for beating GSK down. Or perhaps GSK was restricts information about treatments it doesn’t cases in England each year), and the condi- desperate to break into a market dominated in wish to fund. Vaccination programmes have a tion is on the rise, particularly among young most other developed countries by Sanofi Pas- coercive flavour, but some parents, quite legiti- people: in women 60% of cases occur in the teur. The size of the discount is “commercially mately, may want to delay vaccination until 16-24 years age group. They don’t kill you, but confidential,” said my MP, Dan Norris. I asked more comprehensive safety and efficacy data they can kill your sex life, and in some people him about this because I wanted to “top up” emerge (http://content.nejm.org/cgi/content/ they can be recurrent and extensive. The health the difference so that my daughter can have full/359/8/861). Others simply don’t trust data minister Dawn Primarolo claims that warts are Gardasil with her classmates, within the NHS presented and controlled by drug companies. “preventable,” but meticulous condom use cuts programme. But this choice, apparently, is not They should not be made to feel guilty if they transmission of the human papillomavirus by allowed. decide against vaccination. only 50%. A far safer option is to vaccinate. Parents who choose Gardasil will almost cer- I have worked in sexual health and seen The NHS Choices website (www.nhs.uk) tainly have to pay privately for it. The going plenty of people whose warts have been suc- promotes Cervarix but doesn’t return a single rate in local general practices seems to be £350 cessfully treated. I’ve seen others with exten- hit for Gardasil. Having chosen one vaccine for to £400. We can (reluctantly) afford this, but sive, recurrent warts that need prolonged and us, the government has decided we don’t need many parents can’t. My primary care trust fiddly treatment and florid anogenital warts that information about another that could prevent allows those in the vaccine programme to have resisted just about every treatment. We’ve opted 90% of warts (as well as 70% of cervical cancer). Gardasil if there is “a specific clinical need,” to pay for Gardasil. Unlike the Blairs I’m happy Those administering Cervarix at my daughter’s without defining what this means. For girls to go public about vaccination of my children. school offer no information about Gardasil. who are particularly at risk of genital warts (for I tell parents what vaccine we’ve chosen if they Whatever happened to informed choice? example, those with type I diabetes or exten- ask me, and I’ve written about it in Private Eye. The NHS vaccination site (www.immu- sive verrucas or hand warts) or skin conditions If it was breast cancer, there would doubtless nisation.nhs.uk) is also a Gardasil free zone. that make genital warts particularly unpleasant be an industry supported march on Downing An editorial in Sexually Transmitted Infections (such as extensive psoriasis or eczema), it seems Street, but the genital warts lobby is largely (2008;84:251, doi:10.1136/sti.2008.032755) unethical not to offer them Gardasil. And how under cover. There are no letters to the Times, describes the government’s decision as “a long will it take for a woman with warts to sue and warts have never made it to the cover of sad day for sexual health.” The decision also the NHS for not offering her the choice? Doc- the Mail. But go to www.chestersexualhealth. doesn’t seem to make long term economic tors are supposed to use clinical judgment in co.uk/genitalwarts.htm to see what we could sense. Within three or four years, the editorial individual cases, but the pressure to reduce be preventing. says, the use of Gardasil “would begin to have prescribing costs is relentless. Phil Hammond is a general practitioner, writer, and a big financial payback, as the current estimate The cheap GSK deal for Cervarix applies broadcaster [email protected] of treating genital warts in England every year only to vaccines in the programme. Outside Competing interests: PH has been paid to speak at dinners is £23 million [€30m; $40m].” the programme many doctors will recom- by many drug companies (including GSK and Sanofi So why did the government opt for Cervarix? mend Gardasil, because of the extra protection Pasteur) and NICE. The Joint Committee on Vaccination and it offers, so we may end up with all women Cite this as: BMJ 2008;337:a2186 BMJ | 25 OCTOBER 2008 | VOLUme 337 999 VIEWS & REVIEWS A capital idea FROM THE I handed over my Visa card. The assistant disap- sive, new “quality assured” NHS call centres, with FRONTLINE peared, and the queue grew long and noisy. I twitched. the same sweet apologies about the volume of calls, “Sir, your card has been refused,” he said, confiscating illogical menus, and, eventually, a tick list medical Des Spence the card. I flushed. I was a young and stupid student, algorithm that always seems to end in “call a 999 so why had the bank given me the credit card? ambulance.” Traditional local general practices are From a red call box in the dark driving rain I under threat of closure from shiny new polyclinics phoned my bank manager in Orkney. He knew whose smart managers have implausibly impressive me—his son had been in my class at school. Over the titles and who are driven by short term targets. Cot- crackling line he gave me a thunderous rebuke on tage hospitals and district general hospitals continue conservative fiscal management. He assessed the risk, to disappear. lent me the money, and saved me from being placed We see the rise of superspecialists and the end of on the credit blacklist. I still use the same bank: loyalty the consultant generalist. Doctors are left no longer has no price. knowing their patients or the community and are But these days I can no longer phone my branch in therefore unable to assess risk. Uncertainty is sold on Orkney. Instead I spend hours listening to a panpipe through the medical derivatives market of more refer- version of Copacabana only to be passed to a call centre rals, feeding yet more medical demand and the hugely in Delhi to be asked for a long forgotten password. Or indebted public finance initiative projects. This is a I am sent endless letters for loans “for any purpose” or medical expansionist bubble. seductive glossy pamphlets offering a limitless plati- When the bubble bursts we will be left with junk num credit card because of “my high status.” But I NHS bonds. The time has come for a return to old have long learnt my lesson with credit cards. Gone, fashioned medicine and conservative and restrained it seems, is personal judgment; and knowledge of the medical practice. Above all, we need to regain the customer has been replaced by tick list credit rating. ability to evaluate whether an individual can afford Now, however, banking has come unstuck as a result the personal costs and risk of medical interventions. of feckless lending and greed. These days the talk is Des Spence is a general practitioner, Glasgow of a return to “old fashioned banking.” [email protected] Medicine has seen similar changes. We have expen- Cite this as: BMJ 2008;337:a2203 Saving lives OUTSIDE THE BOX The other day I gave a careers would you save in a week?” throats or sore knees to whom Trisha Greenhalgh talk at a local school. A boy I explained that those stories I’ve said, “Let’s just check your came up to me afterwards and were from a previous life as a blood pressure while you’re said, “Miss, have you ever saved hospital doctor and that I didn’t here”? Or the countless smokers anyone’s life?” save many lives now as a who have left my consulting “Of course,” I replied.