By Phil Whitaker

Copyright newstatesman

Moving to Canada, I had expected things to be different – unfamiliar products in the supermarket, for example, though there have been occasional surprises. I was taken aback to discover that Sainsbury’s Taste the Difference marmalade appears to be something of an export success. And contrary to disconcerting rumours I’d heard, Marmite is available, albeit a special formulation designed to comply with Canada’s food additive regulations. What I hadn’t anticipated, however, was the differences in medications and prescribing practices between our two countries.

The British National Formulary has become ever larger, bulging with the innumerable new drug treatments modern medical science has devised, but I wasn’t expecting to come across quite so many pharmaceuticals I’d never even heard of. One example: Canadian doctors and patients are enamoured of a drug called cyclobenzaprine, used for relieving muscle spasms in acute injuries like back sprains. According to 2016 research, 300,000 cyclobenzaprine prescriptions were issued that year among British Columbia’s 5.7 million population, at a cost of $3.9m (£2.9m). Rather than any objective evidence suggesting the drug lessens muscle spasm, it is probable that its sedative effect just knocks people out so they’re unaware of pain overnight.

Some familiar friends simply don’t exist here. Flucloxacillin is a UK doctor’s go-to for skin and soft-tissue infections but there is no such thing in Canada. Broader spectrum antibiotics like cephalexin appear to be preferred instead. They are prescribed less in Britain because they have been linked to a serious form of colitis caused by the Clostridium difficile bacterium. Rates of C diff infection in Canada are almost 50 per cent higher than the UK, suggesting British efforts to contain the problem are working.

The antipsychotic quetiapine – licensed for treating schizophrenia and mania – would generally only be initiated by a psychiatrist in the UK, and patients taking it long-term would be monitored annually. Canadian colleagues commonly use it to treat insomnia, with no culture of monitoring patients.

While Canadian prescribing might appear more gung-ho than in the UK, that’s not invariable. Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen and naproxen are helpful for muscle and joint pain but they can cause gastric ulceration. The risk of this in the over-sixties is reduced by proton pump inhibitors (PPIs), drugs that switch off stomach acid production. The practice has become subject to mission-creep in the UK to the point where anyone of any age being given an NSAID for however short a time will likely be dosed up on a PPI as well. It has helped make them the second most prescribed drug class in Britain. Interestingly, rates of gastric ulceration appear lower in Canada despite the UK’s overuse of PPIs.

One of my steepest learning curves in British Columbia has been the issue of medication coverage. While GP and hospital services are publicly funded, the cost of drugs is complex. Some treatments are covered by the government; even then, patients on average salaries can be expected to contribute thousands towards their treatment. And if I prescribe something outside the formulary (especially to those without extended insurance), it can prove prohibitive. I started a patient with poorly controlled asthma on an inhaler I would routinely use back home. They were no better when they returned for review – not because it hadn’t worked but because when they went to the pharmacy, the C$147 (£79) cost had been unaffordable.

I am gradually learning to adapt – thinking harder about drug choices and price. There is something to be taken from both medical cultures. While I would never want the UK’s flat-rate £9.90 prescription charge to be abandoned, it shields both prescribers and patients from true costs. Perhaps a keener appreciation of this might lead to better use of NHS resources that will never be enough.

[See also: The battle for Royal Mail]