The polypill available for general purchase?

Charles has frequently shown himself to be antagonistic to the medicalisation of society which he sees as inevitable if some current trends persist. One of them is to offer health checks to all adults between 40 and 75 and another the proposal for the general prescription of the ‘polypill’. When I got my summons for the former I thought I would ask him to update his views on these subjects and did not quite get the initial answer I expected.

‘Charles I have just got my summons for a health check as required by the Department of Health.’

‘Funny, I got mine today as well!’

‘Are you going?’ I asked.

‘That is none of your business!’ he replied with a smile and added ‘But having read the document I would be mad not to, wouldn't I?’

‘It is true that it does not mention that a minority may have doubts of the appropriateness of what is in other words global screening.’ I tried again, ‘That aside, and without disclosing your decision, are you generally in favour?’

‘I am going to duck the question again and ask you to take a step back and consider an entirely different approach.’

‘What do you mean, Charles?’

‘Rather than call everyone in, put a pill containing the ingredients on sale to the general public at a pharmacy.’

‘I thought you were against global polypharmacy, Charles!’

‘I am, Coe, but one has to respect the views of others and there would be no suggestion of coercion.’

‘But what about those at high risk?’

‘Almost by definition these would be very few, but couldn't the pharmacist exclude most of them by taking a quick history and referring them to their doctor?’

I had to admit this was largely true, but followed with ‘And what if they asked for tests, Charles?’

‘In these low-risk people, do they contribute much to the decision to treat or to follow up?’

Again I had to concede, ‘In large trials the incidence of major events, such as death or stroke, is reduced by one third irrespective of the absolute risk or the baseline value of these tests. Furthermore and perhaps surprisingly the benefit gained appears to be independent of apparent therapeutic response. This may be in part due to sampling error particularly with blood pressure. However, I do think that the opportunity should be taken to check on blood glucose levels.’

‘In that case I suggest that the pharmacist should do a finger prick for blood sugar but if they insist on further tests, they should not sell the pill and advise a visit to the GP.’

‘Come on Charles what you are suggesting is contrary to all the principles of scientific medicine!’

‘Perhaps Coe, but you have to agree a strategy which is, in this case, a value judgement before you are able to use science to work the tactics!’

‘How do you mean?’

‘A benefit of one third means that the majority of events will not be prevented and as the risk is low only a small minority will benefit!’

‘Even so, as the numbers of people involved is large a substantial number of events will be prevented.’

‘I accept that, but once you are prepared to treat half the population with little prospect of benefit to any individual, is there any threshold below which you can logically go?’

‘One major event prevented for every 200 years of treatment!’ I suggested.

‘Why not 500?’ he replied, adding, ‘Really it's a matter of opinion, so without an agreed strategy it is difficult to apply the tactics scientifically.’

I looked unconvinced.

‘Think of the potential benefits of the non-scientific approach, Coe’, he continued. ‘First, family pressures excluded, the pill would be taken entirely voluntarily thus ensuring any placebo effect was positive. It would exclude its potential opposite when the roles are reversed and the doctor makes the approach. I once called this the Commoveamus effect. Indeed the required purchase might even enhance any placebo effect.’

‘As per alternative medicine!’ I agreed.

‘Second, it would benefit those at both ends of the spectrum. It would not compromise the well-being of those whose perception of good health depends on not looking for trouble, avoiding medication and, as they see it, the clutches of the medical profession. On the other hand, those who obsessionally demand results and therapy to keep them absolutely “normal” would have less opportunity to ruin their lives and those of their families.’

‘A little harsh, Charles, but nevertheless I can think of the occasional patient in the second category!’

‘And finally, this approach would cost nothing or even make money and, by relieving them of the responsibility for screening, leave more time and resources for doctors to be doctors and nurses to be nurses in looking after the sick!’

‘That's all very well but you haven't answered the question we started with!’

His smile remained enigmatic, ‘I leave you to guess, Coe!’

Cheaper his solution certainly would be, but dare one suggest that it might also actually result in a net benefit in health. One's revered mentors might be horrified but they did practise in very different times.

• © 2010 Royal College of Physicians