NHS England’s announcement yesterday on the future of the Cancer Drugs Fund has reignited an important debate about how to understand ‘value’ in relation to NHS services.
In the coming days, guest bloggers from two cancer charities, Macmillan Cancer Support and Myeloma UK, will be sharing their views about the fund and its future. Today, Nuffield Trust chief executive Nigel Edwards explained a few of his views on the Today programme. This blog expands on some of the discussions we’ve been having. It provides an overview of the issues, and suggests what we at the Nuffield Trust think is a good way forward.
Tough choices
In the NHS and most other health systems, where the amount available to spend on treatments is limited, every decision to provide something to one group of patients effectively denies something else to another group of patients.
It would be easy if there was a simple answer to the question of who should get what on the NHS, but none exists. Instead, politicians and commissioners have to make decisions about how to get best value out of the NHS pound.
As something that one person values highly may be of little value to someone else, these are contested and controversial decisions. When deciding what value the NHS should ascribe to different treatments, politicians and commissioners act on behalf of the public, patients and taxpayers – the people who fund and use the NHS.
In recent years, the broad thrust of the NHS’s approach to determining value, led by the National Institute for Health and Care Excellence (NICE), has been to ensure that “all patients have equitable access to the most clinically [effective] and cost-effective treatments that are viable” . The value of a treatment is measured by taking into account how much benefit it brings to patients in terms of quality and length of life and how much it costs to achieve this benefit.
Drugs and treatments that yield little clinical benefit at great cost are therefore less likely to be funded than those that deliver greater benefit at lower cost.
But there are points in people’s lives where such cost benefit equations may underestimate value. For instance, if a treatment would prolong a dying patient’s life, society may choose to place a higher value on it than on a treatment that appears to offer better value on paper but won’t have such significant consequences.
As scientists target cancer cells with new drugs, these questions have become especially significant for patients whose cancer is incurable but whose lives could be extended by new and often expensive treatments. NICE has responded by designing special criteria against which drugs and treatments given in the last two years of patients’ lives can be evaluated .
Temporary solutions
In contrast with NICE’s approach, the Cancer Drugs Fund, launched in 2011 initially as a stop-gap until a new drug pricing regime was introduced , did not require consideration of cost-effectiveness. The drugs to be considered by the fund were either too new to have been evaluated by NICE or were already “not recommended on the basis of cost effectiveness” .
Many drugs fell into this category, and predictably the fund bust its budget,overspending by £30.5m last financial year. NHS England has now announced that drug cost will be considered by the fund.
Given that when money is spent under the fund it cannot be spent elsewhere, the fund’s continued existence raises legitimate questions. For instance, why should cancer patients have a ring-fenced fund when patients with equally serious non-cancer conditions don’t? Which services are not being funded because money is being allocated to the Cancer Drugs Fund instead? What effect has the existence of the fund had on the prices agreed between the NHS and drug companies?
An open debate
Ensuring that patient and taxpayer voices are heard when the NHS describes value is one way to address some of these questions. In fact, public opinion about the fund is unclear. Beyond consultation exercises when changes to the fund’s approach are proposed, there is little evidence of ongoing patient and taxpayer engagement, in contrast with NICE’s citizens’ council and lay and patient representatives. Some research has called into question the degree of public support for both the fund and NICE’s end of life criteria. So as the terms of the fund change, perhaps it’s time for a broader discussion about how we should value cancer treatments.
There are obvious difficulties in terms of the complex, technical nature of the subject, but in the absence of a better approach, wider public involvement would at least shift the debate beyond the influence of competing interest groups. Therefore, if a robust process demonstrated public support for a ring-fenced fund – a perfectly justifiable value statement – the rationale for the Cancer Drugs Fund would be clear.
What is striking though is the degree of consensus – including from our guest bloggers – that the fund is not sustainable in its current form. One option, as a majority of health leaders who have responded to a forthcoming Nuffield Trust survey agree, is to hand back responsibility for evaluating these drugs to NICE, an internationally renowned institution. This could be on the basis of more generous assessment criteria, if there were public support for this, with interim recommendations for new treatments that have not yet undergone full cost-effectiveness appraisal.
How should the NHS decide which cancer drugs to fund? Let us know below.