The NHS needs a much more strategic approach to medicines management, particularly now that primary care - where most prescribing takes place - is cash-limited.
It should re-appraise the role and value of medicines in the 21st century. It currently spends 12 per cent of its budget on medicines. Is this the 'right' amount to spend?
The NHS should re-evaluate its constant focus on costs, concentrating instead on results and health outcomes. New important medicines should not be delayed, and longer-term planning and commissioning using medicines need to be factored into the new national service frameworks.
The government should plan better for the arrival of 'breakthrough' products from research in genetics and genomics. This relates to funding and a 'no-surprises' relationship with the industry.
The decisions on Viagra show the government at last recognises that the NHS cannot provide everything. It should consult on priority-setting to aid public understanding of where the boundaries lie and clarify whose values are at work. This would give clear guidance to the pharmaceutical industry on what the government would reimburse.
The National Institute for Clinical Excellence's guidelines on approved new medicines appear unlikely to be delivered without extra money to pay for them and encourage their uptake. Prescribers must be incentivised to prescribe such products early, otherwise companies' efforts to satisfy the new evidence requirements make this unfair.
All evidence suggests that healthcare decision-makers have a poor understanding of economic evaluations of new technologies. Health economic tools should be used 'honestly' to allow virement across budgets, including the prescribing 'pot'.
More clarity is needed. What do 'cost-effective' and 'cost-ineffective' actually mean? Is it clinical effectiveness or cost? Is absence of evidence the same as evidence of absence? What are the differences between efficacy and effectiveness, equity and equality, priority-setting and rationing?