Impossible Decisions – What next for the Cancer Drugs Fund?

The decision to de-list 23 drugs has attracted critique and it throws the sustainability of CDF in question

Health Secretary Jeremy Hunt once described choices over drugs for patients with devastating, painful, or terminal, conditions as “impossible decisions”. There is no policy which throws into starker relief those impossible decisions than the Cancer Drugs Fund (CDF), established in 2010 to provide a means by which patients can access cancer drugs that are not routinely available on the NHS. This week, NHS England announced that it would no longer fund 23 life-extending treatments for different cancers, on the grounds of cost-effectiveness. This followed a previous de-listing of another round of treatments in March, also on grounds of cost-effectiveness. Initially intended as a temporary measure, its funding was recently increased from £200 million to £340 million, and it is expected to overshoot that target by a further £70 million.

Last week’s decision to de-list 23 drugs has been met with outrage from patient groups and pharmaceutical companies alike.  Roche’s Chief Executive was reported as branding the UK drugs funding system ‘stupid’ in a speech at Roche’s Basel headquarters earlier this week, whilst the Rarer Cancer Foundation described the cuts as a ‘hammer blow’ to patients.  The ABPI has called the CDF a “sticking plaster covering a seeping wound”.  The charity Breast Cancer Now described the de-listings as a “dreadful day for patients”, and Myeloma UK has cited “critical flaws” with the Fund. Inevitably this puts the Government in a difficult position: improving the UK’s historically poor cancer survival rates has been one of the key health policy priorities.

However, the Government has quietly set much store by Simon Stevens’ ambitious targets for £22 billion in efficiency savings in the NHS, which overspending on drugs outside the PPRS under a scheme like the Cancer Drugs Fund could undermine. The issue is also deeply emotive and highlights the classic tension between economists who stress the scarcity of resources versus increasingly empowered patients who demand the best treatment. The Government does not want to be seen to put a price tag on extra months of life for dying cancer patients, but this is essentially what has to be done.

The continuing row over the sustainability of the CDF is further proof that the broader issue of NHS funding is only likely to intensify on the political agenda. Britain has an ageing and growing population, and many parts of the health service, from GP surgeries to A&E units and hospital trusts, are reporting great pressures and rising waiting times. Money to cover spending on the Cancer Drugs Fund will either have to come from other health services, from greater efficiency targets, or by allowing the Government’s key spending restraints to slip a little. The CDF will act as a test case of which option the Government prefers, since the Fund’s scheduled expiration in March 2016 will force an earlier decision than other areas within the NHS. It is possible that the Government will consider an option similar to official Labour Party policy – which is for a cancer therapy fund that provides money for surgeries and radiotherapies alongside drugs – but even this option would still face strong pressure to fund drug treatments in particular.

Ultimately, though, the Government is now facing an issue of its own making. By essentially overriding NICE’s decisions on cancer drugs by creating the CDF, they have politicised the issue and created an expectation that treatments will be available. This move effectively deprived the Government of using NICE and its independence as a shield from patient and industry anger over the de-listing of treatments. Labour MPs, at the beginning of the new Parliamentary term, have tabled a number of questions about cancer drugs, and may use the issue to put the Government on the back foot on a traditional issue of strength of the party. The Guardian has suggested that Labour will remind the Conservatives of their manifesto commitment to ‘continue to invest in our life-saving Cancer Drugs Fund.’ The fund is due to expire in March 2016, a deadline fast approaching, and it remains to be seen whether the Accelerated Access Review will have produced any workable alternative as part of a broader solution to the problems of the medicines development pathway.

The unresolved issue has damaged the Government’s reputation over what was supposed to be a popular policy. Instead, it has attracted strong criticism from patient groups and pharmaceutical companies when funding for certain treatments is withdrawn. On the other side,  a University of York study argued that the CDF was “particularly poor value” for money and diverted resources from other patient services – and that for every Quality-Adjusted Life Year gained through the Fund, another five were lost elsewhere in the NHS.  The BMJ published an editorial last year that the Fund’s operation would “continue to undermine NICE, duplicate effort, and distort allocation of NHS resources”.

The issue of the CDF is symptomatic of a much more fundamental conundrum that needs addressing – namely how medicines are appraised and assessed for their cost-effectiveness.  How can we ensure that industry is sufficiently incentivised to invest in new medicines while the NHS gets a price it can afford?  The Government’s short-term answer to this is the Accelerated Access Review, set up by George Freeman, which is due to report later this year on how to speed up patient access to drugs, devices, diagnostics and digital health products.  As debate over the CDF rages and we come ever closer to the Freeman report, this is a critical time for the pharmaceutical industry to be engaging with decision makers.  Expect more heated debate in the coming months.