Professor Alan Maynard reviews the reasoning behind government proposals for spending another £200 million on new cancer drugs not recommended by NICE health technology appraisal
The Conservative manifesto pledged an additional £200 million to fund cancer drugs, which the previous government and NICE had been reluctant to fund.
Is this a good idea?
The answer to this simple question is it all depends on what you are trying to achieve.
Friends of the NHS want to ensure that the £105 billion spent on healthcare in the UK is used efficiently. This means that resources should be targeted at those services which give the greatest health gain at least cost.
For over a decade now, the National Institute for Health and Clinical Excellence (NICE) has been evaluating the clinical and cost effectiveness of new drug technologies.
'Why is the government undermining NICE?'
Its processes are less than perfect: the £30,000 per QALY cut-off (higher for certain end-of-life drugs, following the 2009 Richards Review) is too generous and should be reduced to help NHS organisations stay in business.
However, the rigour of its analysis is good, given the often-limited information about the clinical effects of new products supplied to it by the pharmaceutical industry.
Earmarking an additional £200 million for cancer care runs a coach and horses through the work done by NICE.
Why is the government undermining NICE?
The politics of cancer
This destructive behaviour is indicative of further over-investment in cancer services. Investing in cancer care means that we deprive patients with other illnesses of care from which they could benefit.
Why prefer cancer care to mental health care, or the treatment of patients with motor neurone disease, or heart disease or dementia?
Why does the Government wish to invest inefficiently? Its rhetoric is efficiency and parsimony in the face of the recession. Its behaviour is inconsistent with this rhetoric.
The reasons for this inefficiency and inequity are numerous. Firstly, the pharmaceutical industry has produced new cancer drugs of marginal cost-effectiveness for which they are charging very high prices. These prices are an attempt to recoup the cost of inventing these new chemical entities.
But why should taxpayers have to pay for the products of poor R&D by the industry? The Department of Health is both the defendant of the NHS and the industry via the pharmaceutical pricing agreement (PPA) - and when it comes to drug prices they protect the industry by allowing it to charge high prices.
UK PLC demands high drug prices
One reason for this is that the industry claims that over 30 per cent of the world market uses UK prices as a benchmark. Thus if UK prices are high, export earnings are high, and vice versa.
The Department of Health chooses to damage NHS finances, in order to enhance UK export income.
Three years ago, the Office of Fair Trading suggested the use of value-based pricing. Thus products which improved the health status of patients significantly would be priced highly, whilst relatively inefficacious products, such as many cancer drugs, would be cheap.
Industry responded by demanding high prices up front and reimbursement of the NHS if the product subsequently proved of little clinical benefit. One scheme using this arrangement, for beta interferon for multiple sclerosis, has disappeared into a black hole, with no data being reported from a joint Department of Health and private sector evaluation.
After this debacle, why should anyone want to invest further in such opaque and pro-industry policies?
So perhaps if products cannot demonstrate effectiveness, their prices should be low at the outset? If subsequently, the product proved highly effective for patients, then higher prices could be paid later to reward innovation.
So why have the government pledged an additional £200 million for cancer care? Presumably the authors of the Conservative manifesto thought this pledge would garner votes, even if it meant cutting funding to other NHS services. The Americans call this “pork barrel” politics - bring home the bacon to your supporters in the pharmaceutical industry!
The decision is also a product of the power of the cancer industry. Backed by the drug industry, patient lobbies and research organisations continually play the “Oliver Twist game” and demand more!
It appears that they ignore the fact that in doing so, they deprive patients with other diseases of care from which they might get greater benefit in terms of enhanced length and quality of life.
Sadly, the feeble media support this discrimination against non-cancer patients in need of care from a cash-strapped NHS
In a hole with a bad policy? Stop digging.
The politicians will not have the sense or the courage to renege on this silly pledge, as they wrestle with how this additional money is to be allocated and which cancer patients are to be preferred for which treatments. Instead they will laud themselves for the ‘wisdom’ of their inefficiency.
Hopefully, they will not repeat this foolishness and instead reinforce the role of NICE, whilst ensuring that it makes the cost-QALY threshold even more demanding and more likely to prevent the use of marginally cost effective drugs peddled by the ‘ethical’ drug dealers.