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A panoramic debate widens further still – Health Policy Today, 18th August 2008

It is sometimes said that what happens in the US comes to Britain a few years later.  It is not so often commented, however, that the US is beginning to pick up some things from the British system.

Various north American states are looking at regional health plans, and this week two senior Democrats have introduced the Comparative Effectiveness Research Act (2008) to the US senate.  If successful, it will introduce a NICE-style body to the US.  This move is in response to the rising costs and rampant health inflation in the US system, as noted in Alan Maynard’s article (www.healthpolicyinsight.com/?q=node/148) on Health Policy Insight today.

But as a glance at the recent press suggests, such a move will heighten political debate about access to drugs.

Politics back tomorrow, after a short break

After a relatively quiet three weeks of politics, The Times reports that ‘Gordon Brown returns to the fray tomorrow...with a plan designed to show that he is best placed to lead Britain through the downturn, and that he is ready to take on his critics’.   (He will be hoping that ‘Team GB’ will continue to be a successful brand.)  His two key weapons over the next few weeks are his speech to conference, which an aide of his describes as “the most important of his life” and a reshuffle which, papers are suggesting, is being used to threaten or reward colleagues.

The Times says today, ‘One minister who has not helped his job prospects is Ivan Lewis, the Health Minister, who suggested that the Government should consider a tax on the rich to ease the burdens of lower and middle-income families, an idea that has no chance of being adopted.  Downing Street and the Treasury did not comment, but a government source said: “Ivan should concentrate on his day job; otherwise he might not have a job at all”.

One of the political issues that has boiled over GB’s holiday is access to expensive drugs and the role and workings of NICE.

‘It could be you’ – Panorama explores the postcode lottery for healthcare

During the Panorama programme tonight (BBC1, 8.30), the chief executive of NICE, Andrew Dillon hints that his institute ‘may not be able to meet the Health Secretary Alan Johnson’s recent pledge to try to bring decision-making on new drugs down from two years to just three months’, which is one of the ways the Government has tried to diffuse the row on access to new drugs.

The real focus of the Panorama programme is the differing application of rules.  So while one consultant might give you a drug in one place, in another they will not.  (A survey of PCTs in the HSJ last week suggests that PCTs are rarely informed when it does happen – doctors or hospitals make the decision locally).

A consultant tells the show that the inconsistency is at PCT level.  “If you apply to Cheshire, they tend to fund patients that have exceptional circumstances ... If we apply to the Manchester PCT then in the eight applications we’ve made they’ve only accepted on for funding”.

Andrew Dillon tells the programme that it is up to PCTs to be consistent when deciding to make drugs available.  “It shouldn’t make any difference where you live.  There ought to be a common basis for making decisions about exceptional circumstances and I think anybody who uses the NHS for their care is entitled to expect that".

Novelist Terry Pratchett says people should be allowed to pay privately for drugs and not lose their NHS entitlement

Also featuring in Panorama is the novelist, Terry Pratchett. In yesterday’s News Of The World, he wrote a long piece about access to drugs.  He made the point that he could get access to Viagra but not to Aricept – a drug that has not been approved for ‘the mild stages’ of the disease (except in Scotland, where it is available).  Even though he has mild symptoms, Pratchett says the drug has helped.  He no longer fumbles with buttons and can put his seat belt on.

You can watch a preview of the programme here - http://news.bbc.co.uk/1/hi/programmes/panorama/7563041.stm.

He makes the point that Aricept is cheap – at £2.50 a day.  ‘The bad news is there are 400,000 Alzheimer’s sufferers in the UK so Aricept has been ruled out’.  He is able to buy the drug, but worries about people who can’t.

He would also like others to be able to buy drugs privately, for other conditions without losing their NHS care.  ‘I would like the NHS to take a serious look at this whole scandal because by banning copayments they hit at people like my parents who were frugal and saved.’  In response to accusations that this will result in a two-tier system Prachett says, ‘we already have a two-tier system.  You can already go to your doctor and then decide to go private for a lot of things.

Whose fault is it that the cost of drugs is so high?

Andrew Dillon is not the only senior figure from NICE to make the news.  In a wide-ranging interview with The Observer Michael Rawlins, the chair of NICE, made some headline-grabbing comments.  He said, “we are being told we are being mean all the time, but what nobody mentions is why the drugs are so expensive”.

In his view, there are incentives for high prices, including the link between salaries and share price.  “It is not in their interest to take less profit, personally, as well as from the point of view of the business”.

The ABPI speaks up for the pharmaceutical industry

The Association of the British Pharmaceutical Industry (representing more than 75 pharma firms in the UK) said it was “not aware of any attempts to fix prices in line with profits or individual earnings”.  It added that in real terms prices have fallen by twenty per cent in 10 years, and made the point that R&D involves massive investment.

In his interview, Michael Rawlins notes the fall in cost of drugs, where the patent has expired and cheaper versions are used.  He says this is an important reason why costs were so high for protected drugs and was a cause of the push for higher profits.

The NHS constitution and the copayment review – opportunities to seal this debate?

There are two letters in The Guardian today, published side by side.  They each point to forthcoming policy announcements, and an air of expectation over how the Government will respond.

Rachel Rowson of Macmillan Cancer Support says, ‘we are heartened that the draft NHS constitution seems to...include proposals for guidance that will make PCTs responsible for informing patients why they have made their decision.  Macmillan will be responding the consultation to ensure these important proposals are not warered down.  People affected by cancer can find out what to do if their treatment is not funded on our website: www.cancerbackup.org.uk’.

The other letter writer is Jeremy Hughes of Breakthrough Breast Cancer who notes that ‘the current system is confusing for patients’, ‘with PCT “exceptional case reviews” and reports of wide variations in access to treatments, patients are caught in the middle’.  ‘This is why Professor Richards’ review of the consequences of additional private drugs for NHS care is vital.  ‘It is about time that patients got the clarity they deserve’.

The Government will have a hard time pleasing all when they respond on the consultation and on copayments.

Two US senators propose a NICE-type body for the States

Friday’s BMJ reported that two Democrat senators have introduced a bill into the Senate that would establish a body which will identify the most effective health treatments.  It is called the Comparative Effectiveness Research Act, 2008.   In effect, it will introduce a NICE-type body into the US system.

The two senators are respectively head of the Senate finance committee and the Senate budget committee.  Their idea is for a private, not-for-profit, institute – to prevent political interference – with a wide range of participants from the public, government and private industry.  The idea is supported by the Institute of Medicine.  One of the senators, Max Baucus said, “In 2006, America spent more than $2 trillion on health care.  By any standard, this is an enormous figure...Of the $2 trillion, only 0.1% was spent to assess what words and what doesn’t.”

The senators’ institute ‘would be governed by a board of 21 governors who would include the secretary of the federal Department of Health and Human Services and the directors of the federal Agency for Healthcare Research and Quality and the National Institutes of Health.

As we have seen over the last few days in England, setting up such a body is only the start of the political problems.