Uncontrollable forces in debates on the availability of drugs - Health Policy Today, 26th August 2008

The debate about the availability of expensive drugs is changing in nature.  It is being linked to a need for more insurance, to provide for expensive drugs, amid reports that the European Commission proposes to allow pharmaceutical firms to provide information directly to patients about their products, on the radio, the internet and in newspapers.  

NOT NICE AGAIN

NICE now regularly features in the politics pages.  As the Economist notes this week, it is really ‘only recently that it has run into the sort of bitter controversy that always seemed likely to dog such a body’.

This weekend, a group of 26 oncologists wrote to The Sunday Times to call for radical change in the way that NICE makes its decisions.  In response, NICE published a defence of its methodology.  In an increasingly political debate, the NICE chief executive challenged the specialists to decide which treatments should stopped to finance increased spend on cancer drugs.

Kevin Barron, the Labour MP who chairs the Commons Health Select Committee defended NICE to the Guardian .  He said the NHS was not “a bottomless pit” and someone had to take difficult decisions.  “NICE is doing it better than what we had 10 years ago which was clinicians making the decisions”.

CHANGING RELATIONSHIPS BETWEEN PATIENTS AND CONSULTANTS

Doctors don’t want to deny care, as supported by a survey by the charity Myeloma UK, reported today.  It shows that doctors would rather not set out all the available options only to later explain that some are not available.  Around a quarter of myeloma specialists admitted hiding the facts about treatments that may be difficult to obtain on the NHS in order to avoid distressing or confusing patients.

Yet in the current debate, it is doctors in particular who are seen as championing the rights of individuals to expensive drugs.  It is NICE’s methodology that irks them.

‘Mean survivals obscure the fact that some patients will obtain prolonged benefit from these drugs’.  

WHAT ABOUT THE INDIVIDUALS WHO WILL BENEFIT FROM TREATMENTS?

In the context of the current debate about available drugs, writing in her BMJ column, Iona Heath also points out that ‘it is highly likely that in all the trials considered by NICE there will have been a very small minority of patients who responded to each of the treatments much better than most’.

Hearing this, those individuals who might benefit seem less happy to have their case ruled on according to the average. Many feel as though they are being denied care, either because NICE believes the intervention not to be cost-effective to a population as a whole, not them in particular.  And if they accept limits on social spending, they also feel denied, because they are, at present, unable to purchase the drugs out of their own pockets and still be eligible for NHS care.

Social changes are not within the control of governments, and Reform will argue that it is impossible to try and prevent the introduction of co-payments and insurance, if people want it.  If the Government tries to prevent this, it will force people to leave the health service, creating a two-tier system.

AN IMPORTANT EUROPEAN DIMENSION COMES TO THE DEBATE

The weekend after next, the think tank Reform is expected to publish its vision for the NHS.  It is likely that it will weigh up the cost of new treatments, contrast this with a strong social appetite to access these drugs, with private money if needs be, and call for a greater role for insurance in English healthcare.   The leading doctor within Reform is Professor Karol Sikora who was also the first signatory of the letter criticising NICE, published in the Sunday Times.

A key issue in that letter is why the kidney cancer drugs are not available in England when they are in other European countries.  They write, “we have seen distraught patients remortgaging their houses, giving up pensions and selling their cars to buy drugs that are freely available to those using health services in countries of comparable wealth."  

At present it is illegal, all over Europe, for drug companies to advertise prescription-only drugs directly to patients.  However, the European Commission has put forward proposals that will allow pharmaceutical firms to give information to patients – in newspapers, on the radio and on the Internet.

An opinion piece in The Scotsman argues that this can’t come soon enough, reflecting a view that governments put cost considerations before clinical effectiveness.  This kind of information, then, will allow us to see the benefits of the treatments.  The problem with this approach is that there will be counter-view, only promotional information, unless this is carefully regulated.

This move could increase the clamour for expensive drugs.  The push to be allowed to be able to buy drugs directly reflects a changing social attitude – more individualistic and less collectivist.  

THIS DEBATE IS NOT GOING AWAY ANY TIME SOON

The Guardian today reports that the Kidney Cancer Support Network will stage a protest outside the London offices of NICE.  Expect it to get a lot of press coverage.