Drugs and treatments

Speech I made on an amendment to the Policy & Resource Plan regarding a review of drugs and treatments.

Sir, the purpose of this amendment is to provide more detail around the review that the Committee has already stated it would undertake as part of the Partnership of Purpose in relation to its drugs and treatments policy and to provide assurance that it would be undertaken in this political term.

I would like to thank Deputies Roffey and Merrett for their interest in this area and can confirm that this amendment was submitted after consultation with both of them.

There have been a lot of comments in the media from those with a special interest in this matter, some better informed than others and I think I should take the opportunity now to correct some of the misinformation that has been put out there and give some context as to how we have got where we are today.

Firstly, the current policy has not just been brought in, as has been implied by some commentators. Whilst it has its origins in 2008, the reality is what we have today can be traced back far further.

Although some have stated otherwise, NICE guidelines with respect to new drugs have never been automatically adopted in Guernsey either by HSC’s or ESS’s predecessors. Indeed, should members wish to take a walk down memory lane they could read the 2003 policy letter from the then social security authority that set up what is now known as the white list, ie its own approved prescribed medicines, which makes no reference to NICE but does make it very clear that Guernsey should decide what drugs it approves and what it should not. It also refers to the issues that this might cause with respect to patients being treated in tertiary centres where they may be prescribed drugs that were not approved in Guernsey. To say that what we are considering now is therefore something that has been brought in through the back door in recent years is therefore far from the truth. It has been the case for over 15 years.

But, lets look at what happened from 2008, after Deputy Roffey was last in the States and held my job. There was the little issue of the financial crash, zero/10 and FTP, all of which have, in various ways resulted in the need for greater financial restraint.

Also, since then there has been the introduction of an end of life premium in the UK, where the Quality Adjusted Life Year up to which those specific drugs would be approved was increased from £30k to £50k. It has also seen the introduction of a Cancer Drugs Fund in 2010 and NHS England’s Commissioned Drugs for Rare Diseases. BTW The latter two need to be considered in the context of the UK’s own economic strategy in terms of supporting its R&D industry. 

Now a recent King’s Fund Review described the Cancer Drugs Fund as a “quick-fix” election promise that wasted more than a £1 billion and left dying patients in agony. Just one in five of the medicines offered by the scheme was capable of benefiting recipients, which they branded a “political failure across the board”.

Set up in 2010, the fund was designed to pay for treatments that had failed the standard NHS cost-benefit criteria

It has now been reformed and sits under the responsibility of NICE but it’s too early to tell whether that has made a difference.

In terms of rare diseases and what are called orphan drugs, the costs aer eye watering with figures approaching £300k per course of treatment. Now a rare disease is one that affects under 5 per million people so it might be thought this wouldn’t really have much impact on Guernsey. However, whilst a disease may be rare, it is not rare for people to have such a disease. It has been estimated that anywhere between 6-8% of the population might get a rare disease sometime in their life. So, that is the UK.

What about Guernsey? The current policy, G1033, is ethically based by setting down key principles, decision rules, criteria and conditions which ensure CHSC operates within an appropriate legal and ethical framework. And the reality is that, for routine drugs we do generally follow NICE, although we do do more such as approving Avastin for Age Related Macular Degeneration, which NICE still doesn’t do despite the fact we have proved its effectiveness and we know there are those in the UK that don’t understand why it doesn’t.

However, as we seek to transform Health and Care, and to ensure we meet the key principles of our Partnership of Purpose it is opportune for us to review the policy now. We are also aware that it may be more restrictive than Jersey and the Isle of Man, although the extent is unclear as we know Jersey at least doesn’t have a Cancer Drugs Fund and neither have a Commission for rare diseases, but our review will consider what is done in our fellow Crown Dependencies.

So we will undertake a review and return to this Assembly with our recommendations, which members are free to accept amend or reject and this will feed into the development of the Universal Offer.

However, its worth highlighting a few points now, that will need to be considered when formulating our recommendations and which members may wish to think about before we do come back with our policy letter.

Firstly, should we effectively allow a third party organisation in another jurisdiction determine how we spend our money? And, if we should, why should it be the UK? The NHS is in financial meltdown, partly as a result of the UK’s drugs and treatments policy which has resulted in both a postcode lottery and the cutting of services elsewhere, such as mental health and primary care. Our current approach is very similar to that of Australia and NZ which does not have worse, and in many ways has better outcomes than the UK.

Secondly, we can’t ignore what’s coming around the corner. The coming years are going to see a growth in the development of precision medicine. T the customization of healthcare, with medical decisions, treatments, practices, or products being tailored to the individual patient. This is revolutionary stuff. It is also going to need a change in how drugs are approved, whatever we do. Should we therefore just follow what one organisation does, when, as a smaller body we could respond more nimbly to these changes? When we actually have a policy that is far more advanced than the UK already?

And finally, It has been estimated, that were we to adopt just NICE drugs automatically it could cost around £4m, that excludes treatments that we don’t routinely provide, such as for sleep apnoea, so consider that £4m as a minimum. It would also make budgeting harder as the size of our population would mean greater fluctuation in costs year on year. This would mean, in the current system that the Health Service Fund as well as HSC’s general revenue budget would be put under pressure at a time when demand will rise as the population ages. The likelihood of cancer increases with age for a start. It should also be noted that whilst the drugs bill has been well managed over the last decade, and certainly better than the NHS with greater use of generic drugs, it is not as if the bill has gone down. In 2008 the annual expenditure from the HSF was £14.9m, and it now stands at £18.1m.

Putting aside the fact that spending more money on drugs doesn’t necessarily lead to better outcomes, were we to adopt the UK’s drugs and treatments policy which would mean greater expenditure, the questions we need to ask are should we cut health and care services elsewhere, or do we throw more money at it and if the latter where does it come from? You will get the drugs but are you happy to wait in A&E for over 4 hours, or wait months for mental health treatment in the UK?

HSC has shown how it can operate more efficiently without cutting services but there is a limit. So, expecting us to absorb the cost is a no no. We will need more money. And on that front whilst we might like to reference Jersey and the IOM they do both have a consumption tax. Is it a quid pro quo? I don’t know but these are the things we should be thinking about.

Whether G1033 is too restrictive or not, it is designed to ensure that we do not go back to the old days when a well orchestrated campaign meant certain drugs and treatments were adopted whilst other services suffered and don’t forget the big pharmaceutical companies do fund lobby groups and regularly provide information to the media on the latest wonder drug. It may not be apparent to people out there but is certainly something I have noticed since I have been in this job. And that leads me to my final point.

The Committee will come back with its findings and its recommendations but at the end of the day this is all about how much more is the assembly, or the community, willing to pay. And whatever it decides, it will never be enough. There will always be more treatments that can be given more equipment that can be bought and more services that can be provided. Difficult decisions will always have to be made and that is why it is important that whatever is ultimately decided in terms of drugs and treatments our policy is open and transparent and considers the needs of the population as a whole and not those who shout loudest.

And just finally, there is a view, which I have heard from some amongst us that how can we know any better than the learned bodies of the UK. Well, why can’t we. Quite frankly I think that does a complete disservice to both my Committee who are not exactly lacking in brain power and our staff who have over the last 2 years demonstrated they can turn a tanker around and do what the NHS has singularly failed to do. Why should we be following the UK when they should be taking a leaf out of our book?

Whatever, we will review our policy and I can assure members what we develop will be in the best interests of the people of the Bailiwick.  And we can show in health care, just as we have done with our finance industry, that  far from being followers we can be leaders in the field.

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