How we spend our money

What links gambling, negligence claims, and spending on HIV drugs in South Africa (apart, of course, from their appearance in this week's BMJ)? Well, possibly the idea that there are better ways to spend the money.

To take the most controversial first, Karen Zwi et al argue in their opening editorial that the recent reduction in the price of antiretroviral drugs for HIV in developing countries is only of secondary importance for managing HIV in South Africa (p 1551). Drugs for preventing mother to child transmission are cost effective, they agree, but “the real solutions to the AIDS epidemic . . . are a lot less glamorous”: improvements in basic health services, prevention and treatment of other infections, and improved status for women. Robert Szabo and Roger Short would add male circumcision to this list. Because circumcised men are two to eight times less likely to become infected with HIV than uncircumcised men, they argue that circumcision should be an additional preventive strategy in countries with a high prevalence of infection (p 1592).

Nearly everyone who has bought a lottery ticket probably reckons afterwards that the money could have been better spent, but for some people gambling is pathological—about 1-2% of adults in the United States, Canada, Australia, and New Zealand, according to Rachael Volberg (p 1556). She warns that British lottery operators are following a global trend towards increasing opportunities for gambling. When gambling is liberalised it initially produces extremely high participation, followed by stablisation and then the introduction of new games to revive interest and increase spending. Thus Britain's weekly lottery was followed by instant scratch tickets, a second weekly draw, and another weekly game, and the next licence is likely to include a daily draw.

In 1997 a BMJ article argued that it was unfair that awards of damages in the NHS should compromise patient care (1997;314:1821). Paul Fenn and colleagues don't discuss this aspect in their analysis of the current cost of medical negligence in NHS hospitals (p 1567), but they do argue that some reports of future liabilities are wild overestimates. They show that the rate of negligence claims rose by about 7% a year in 1974-8. On average, however, only 30% of claims result in compensation, and they estimate that the total annual cost of medical negligence litigation is about £84m. Not as much as some widely quoted estimates, but still a big opportunity cost.

And finally, the debate about “lifestyle” drugs, which continues in the letters (p 1605), is implicitly about whether the NHS should spend its money on “better” things.