Will the Coalition’s cancer drugs policies work?

During the election campaign the Conservative Party frequently highlighted the issue of cancer drug rationing including David Cameron himself during the leaders’ debates.

Since then the Coalition Agreement has reaffirmed a commitment “to reform NICE and move to a system of value based pricing so that all patients can get the drugs and treatments their doctors think they need” and the prime minister has stated his intention to push ahead with a £200 million Cancer Drug Fund (CDF) to meet a list of expensive cancer drugs that the National Institute for Health and Clinical Excellence (NICE) had previously rejected.

So will this mean and end to rationing of drugs? Well, during a supposed age of austerity it seems like a very big commitment.

Firstly, the cost of the CDF covering historic NICE decisions has been estimated by BBC Radio 4s ‘The Report’ to cost closer to £600m rather than the £200m originally budgeted by the Conservatives. To put that in perspective: the total NHS cancer drug bill in 2009 was approximately £900m.

Secondly, there is the growing numbers of and demand for new cancer drugs. The US cancer drug spend per capita market for biological therapies (including most new cancer drugs) grew at about 20 per cent annually between 2001 and 2006. So going forward the costs – above and beyond the historical commitments of the CDF – are likely to inflate rapidly.

Thirdly, there is a question over the mooted NICE reforms. Whilst the phrase ‘value based pricing’ is somewhat opaque, most people take this to mean an expansion of Patient Access Schemes (PAS). The Labour government initially set these up in response to the rejection of costly or unproven drugs by NICE.

Under PAS schemes the NHS pays the full cost of a drug or treatment to the pharmaceutical company whilst monitoring the response or outcome of patients over time. If the drug proves less worthwhile than mooted, then the NHS is refunded part of the cost.

In practice however PAS have proven very costly to administer and possible refunds have often been lost due to onerous monitoring requirements. Now the largest such scheme providing beta-interferon and glatiramer acetate to MS patients (a treatment previously rejected by NICE) has been angrily denounced as “a fiasco” and a “costly failure” by editorials in both The Lancet and the British Medical Journal.

The MS patient scheme costs about £50m a year but when monitoring showed no benefit to patients, the ‘independent advisory group’ perversely decided that no refund was necessary. Notwithstanding this odd decision, PAS schemes generally and for cancer drugs particularly have not saved money.

Lastly, there is a question surrounding the perhaps hurried phrase in the Coalition document “the drugs and treatments their doctors think they need”. Well… with no disrespect to doctors they aren’t always the best people to judge what drugs their patients need – that would be medical statisticians. There are a surfeit of new drugs that might work especially for rare cancers (where there is a lack of trial data) and terminal cancers (where other options are limited).

Will the new policy really give doctors carte blanche to prescribe anything? And if there are no restrictions, won’t doctors or perhaps hospital trusts come under extreme pressure to prescribe more and more? Contrary to perceptions in this country, even in the US access to new cancer drugs is restricted either by cost to the patient or by Medicare.

Certainly the Conservatives during the election and now the Coalition have done nothing to dispel the impression that all forms of cancer drug rationing will come to an end. In lieu of inflation-busting increases in the NHS budget one of two things can happen now: either a lot of patient advocate groups are going to feel betrayed by limited increases in drug access, or a large – heaven knows how large – increase in the cancer drug budget will inevitably lead to cuts in other areas.