The Government is reported to favour a system of value-based drug pricing. Value for money is, of course, important whenever public money is spent on anything. Pharmaceuticals are no exception.
Discussion about how to obtain the best value from NHS drug spending continues. Various possible approaches exist. The path is paved with good intentions but many potential pitfalls need to be avoided.
I fully support the Government decision to remove NICE’s drug rationing role. This change was one of the proposals advocated in my submissions to the Department of Health in response to last summer’s White Paper. My reasons were covered on page 9 of the relevant document, which can still be downloaded from my website www.researchideas.co.uk by clicking on General Comments there. I continue to argue for a strong role for NICE in advising on the best way to treat patients but against a direct role in pricing or prescribing decisions. In my view the intellectual basis for this standpoint is very compelling. To suggest that it arises from pressure from the pharmaceutical industry is a political slur.
The issue of a so-called “postal lottery” is a difficult one. If possible, a postal lottery should be avoided because it is unfair. However, there is also a need for patients to be educated about how doctors reach prescribing decisions. Doctors do not all prescribe the same drugs under the same circumstances. There is often debate within the medical profession about what drug regimes are best and under what circumstances. For this reason different panels of experts and authorities in different countries often have different prescribing guidelines even when neither drug prices nor differences between patient populations are relevant. The extent to which any drug is prescribed can vary greatly from doctor to doctor, from medical practice to medical practice, from region to region and from country to country. There is therefore always an element in drug prescribing that could be described as a postal lottery. The effect is particularly striking when individual doctors get out of date. This happens not because of professional incompetence but because there is far too much medical literature for any general practitioner to be fully on top of all research findings.
If doctors are prescribing drugs and are competent to handle a wide range of NHS commissioning, then they ought to be able to handle drug rationing should the need arise. Rationally the doctor/patient relationship should suffer no more than whenever the doctor’s consortium does not commission something that would improve medical outcomes. Not everything good can be funded. In medicine, like in the armed forces, life and death decisions go with the territory.
Despite all the rational argument it is galling and politically unacceptable for one patient to die when a drug might have saved him but has been withheld purely because of price, if patients elsewhere are receiving the product. How can we stop this happening? We cannot make drug companies sell drugs much more cheaply than in other countries because this is against their commercial interests. In that situation the companies would prefer not to supply the products. A national solution is needed to cover very expensive but undoubtedly life-saving products. Apart from the Government just paying the bill the options include:
- more and better thought-out patient access schemes sharing risk with drug companies.
- contributions from outside Government funding e.g. charities, employers, patients, insurers.
- drug pricing schemes that control a company’s total NHS revenue or profit rather than individual drug prices.
- education of doctors about ways of avoiding waste without compromising outcomes e.g. not giving an unnecessarily high dose to a patient of low body weight; having regard to NICE’s views about how to achieve the best medical outcome.
I believe that with goodwill from Government, doctors and the pharmaceutical industry, a way forward can be found that does not require life-saving drugs to be rationed but also enables the total NHS drug bill to be controlled at acceptable levels. At the same time R & D can be encouraged and investment in the UK supported. I have posted on my website www.researchideas.co.uk a link to a document giving more detail on my thoughts about drug pricing.