Who Really Benefits from Britain’s Medical Cannabis System?

Written for Business of Cannabis by Saxon Coop, Founder & CEO of Toke.

In March, The Times reported that a single doctor had issued nearly 46,000 cannabis prescriptions in the space of five months. The sensationalist headline caused understandable alarm. But the figures, drawn from an unvalidated NHS Business Services Authority dataset, tell a more complicated story than the headlines suggested.

An independent analysis of the same data by Business of Cannabis found that the 46,000 figure does not represent prescriptions at all. It represents “items,” which are the number of times a product appears on a prescription form. A single appointment generating a prescription for three cannabis products would produce three items in the dataset. The FOI itself acknowledges it is opaque and unvalidated.

A fundamental limitation of the data is that it’s not clear. This lack of clarity on medical cannabis holds the entire industry back, as without clear data and transparency, nobody actually knows the realities of patient access to medical cannabis. This leads to misinterpretation, misunderstanding, and missed opportunity to deliver improved patient outcomes to the people that need it the most. 

Over 60,000 private cannabis prescriptions are issued annually, with a reported 130 per cent year-on-year surge. Clinics are charging as much as £200 for an initial consultation. For those who cannot afford such fees, they have no alternative but to live in pain or to source cannabis illegally. How has it come to this?

The breakthrough of medical legalisation in 2018 has been undermined by draconian prescribing guidelines from the National Institute for Health and Care Excellence (NICE). These guidelines are so restrictive, they may as well constitute a ban for most patients. Before a GP can even consider the request, patients must first have tried at least two recognised therapies. Prescriptions must also come from a specialist, not a GP. Although confusingly, GPs can reissue prescriptions after a specialist has initiated treatment. For chronic pain, one of the most common reasons patients seek medical cannabis, NHS doctors are actively advised not to prescribe it. 

We should not blame doctors unfairly, however. The NHS is simply not set up to support meaningful access. Research from the Medical Cannabis Clinicians Society found that many NHS hospitals lack even basic protocols or routine pharmacy stock for cannabis-based products. This is largely the result of decades of political and social stigma. As a publicly accountable system run from Whitehall, the NHS is inherently risk averse. Without the necessary effort to change perspectives, many consultants retain outdated views on cannabis. 

Restrictive prescribing is typically justified on the basis that the evidence for medical cannabis is insufficient. This claim often goes unchallenged and deserves greater scrutiny. 

For example, a recent study published in The Lancet Psychiatry (Wilson et al.) last month presented the largest meta-analysis to date of cannabinoids for mental health and substance use disorders. After this study was published, headlines claimed that there was no evidence that cannabis helps anxiety, depression, or PTSD. 

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But the review identified just 54 randomised controlled trials spanning 45 years, covering a total of 2,477 participants. Of those 54 trials, the authors themselves rated 44 per cent as having a high risk of bias. Evidence certainty for most outcomes was graded “very low” or “low” under the GRADE framework. And for depression, there were no randomised controlled trials at all. 

There is a critical difference between “the evidence is insufficient” and “the evidence shows it doesn’t work”. The Wilson review says the former; the headlines, and inevitably the policy response, treat it as the latter. An absence of evidence is not evidence of absence. When the total evidence base amounts to fewer than 2,500 participants across four decades, the only honest conclusion is that we do not know enough. This should be a case for more research.

Instead, this lack of knowledge is used to justify blocking NHS prescribing while giving a huge uplift to the private market. While the NHS treats the evidence threshold as impossibly high, the private sector almost entirely disregards it. The incentives are perverse, as revenue is directly correlated with prescriptions, punishing caution and rewarding volume. That is a predictable result of a broken system, not an indictment of the doctors working within it.

Too often, the conversation intended to resolve this crisis becomes repetitive and myopic, focusing on improving NHS access alone. But this misses the point entirely, and risks making the problem worse.

No country has succeeded in making a medical-only cannabis system work in isolation. Take Germany, for example: it expanded medical access before moving towards a broader legal market, because a medical-only framework cannot sustain the supply chains, the research base, or the political normalisation needed to make prescribing routine. 

The only viable solution is a regulated recreational market that makes the medical system functional. Clinical need and general consumption should be separated entirely, with NHS prescribing reserved for patients with no other alternatives and private prescribing for those who choose medical cannabis over conventional treatments. Underpinning both routes would be a network of regulated medical dispensaries and access to high quality research and evidence for both patients and prescribing clinicians. 

What is clear is that the current system benefits no one but the private clinics that have filled the void. And without transparent, validated data, we cannot even measure how badly it is failing. Patient safety should have been the priority from day one. A regulated market alongside a reformed medical system is the only evidence-based path to making medical cannabis work. 

The question is no longer whether reform is needed. It is how much longer the government intends to let patients pay the price for its failure to act.