Deborah Cohen: Access to NICE approved drugs

Deborah CohenIn the midst of his heavy schedule, defending his controversial NHS reforms, Andrew Lansley, health secretary for England, has found the time to form a new expert panel which will contribute to a government report on the NHS Constitution.

This will set out in one place what patients can expect from the NHS, including rights:

• to be treated with respect and humanity
• to have access to NICE-approved drugs
• to make choices about their NHS care

There’s very little here that few people could argue with–that people are treated with decency and their choices about their care are respected. What’s interesting is the middle option—that patients should have access to NICE approved drugs. It seems perfectly logical at first sight—a way around the so-called postcode lottery.

But it’s exactly this that representatives of the drug industry have been lobbying for. Such a stance might sound like companies are softening on a previously hostile relationship with NICE—an organisation seen to prevent the rapid uptake of new drugs.

At an ABPI meeting last year, Ramona Sequeira, managing director of Lilly UK, stated that patients also need better access to NICE approved drugs. 

There is an industry view that UK doctors are conservative in their prescribing patterns and medicines are not prescribed once NICE have given them the green light. Commissioners tend to go for generics. As Ms Sequeira put it the UK only spends 0.9% of GDP on medicines compared to 1.2% in the rest of EU.

“The NHS is very good at the uptake of old and very cheap technology. The uptake of innovation is a problem in the UK,” Paul Catchpole, value and access director, of the ABPI, said

Today, a PharmaTimes Director’s Club event at the King’s Fund health charity will argue that “there is real and present industry concern that the medical management community is over-focused on medicine costs rather than health outcomes.”  A new report called ‘The Innovation Health and Wealth – Accelerating Adoption and Diffusion in the NHS‘ will highlight these concerns.

The push for NICE approved drugs is a clever drug industry move and one that seems to have paid off.

 And it’s a global tactic too. Lobbying by the Japanese government on behalf of the drug industry in the build up to the UN summit on non-communicable diseases in New York last September urged the use of “high quality” medicines—a reference to branded as opposed to generic drugs. They also pushed for “acknowledged public health best practices,” as opposed to cost effective interventions.

But it is worth thinking about what the right to guaranteed access to NICE approved drugs might mean for a cash-strapped NHS.

NICE approves lots of drugs that aren’t always the best or most cost-effective option for certain conditions. In many cases the “new” more expensive version might be the best of the lot–but in many cases the benefit is marginal and not worth the cost

For example, NICE has given the nod to both analogue and human insulin. However, analogue insulin is far more expensive than human insulin and NICE guidance—produced alongside drug appraisals— says that analogue should only be used in defined circumstances in type 2 diabetes.

A paper in BMJ Open concluded that given the high marginal cost of analogue insulin, adherence to prescribing guidelines recommending the preferential use of human insulin would have resulted in considerable financial savings over the period. It estimated that if all patients using insulin analogues could have received human insulin instead, the overall incremental cost of analogue insulin was £625 million.

So where would that leave doctors who follow NICE guidance? It would leave doctors vulnerable to concerted campaigns by some industry funded patients groups who argue for the latest treatment—even if the evidence base does not support its preferential use. If patients wanted the more expensive drug—with no obvious clinical benefit—would that leave a doctor’s prudent decision redundant? All these issues need to be clarified before committing such an ill defined right to legislation.

Deborah Cohen is investigations editor, BMJ