Falling behind the NHS?

Twenty-seven of these drugs, passed by Nice, the committee that assesses the quality of evidence for use, are not available here.

Among the ‘developed nations’, the UK has the worst record for cancer survival rates. The adoption of newer therapy drugs has been very slow there due to bureaucracy and funding problems. If we are behind them in terms of cancer funding, and the supply of effective drugs, this must be a situation the oncology staff must be extremely depressed and frustrated about.

We are very lucky to have such a dedicated and hard-working department at Bulstrode oncology, as many patients will attest to. There has evidentially been a steady erosion of the situation over the last 10 years, when we were ahead of the UK in applying cancer treatments.

P. HUDSON (Mrs),

Address withheld.

Editor’s footnote: A spokesman for Health & Social Care replies:

There has been a considerable amount of media coverage on the matter of Guernsey patients being denied access to Nice-approved drugs following Deputy Peter Roffey’s Rule 11 and Rule 14 questions at the States meeting which commenced on 28 February 2018.

HSC and ESS would, in responding to your reader’s letter, like to use this opportunity to provide clarification regarding the decision to fund Nice-approved drugs and drug treatment regimes. Responsibility for, and the funding of the provision of, medicines is split between HSC, which is responsible for medicines used within its facilities, and ESS, which is responsible for those prescribed for use in the community. While recognising the impact of decisions on individual islanders, the committees seek to ensure limited resources are used fairly and equitably, maximising the value of care delivered to the population as a whole.

It should be noted, of the 27 drugs and drug treatments referenced by your reader and by Deputy Roffey, only two have ever been requested for local patients. In practice many Nice-recommended cancer drugs requested by local doctors are approved and are available. So, the fact that these drugs are not on Guernsey’s prescribed list does not mean they have been refused.

Nice guidance is treated as advisory and provides a useful review of evidence and cost-effectiveness. It is not appropriate for Nice guidance to be automatically adopted as this would fail to reflect the unique health and social care responsibilities of HSC, the budget available or the additional costs inherent in delivering services in a small jurisdiction.

It is also important to note that Nice guidance reports typically set out standards of care or patient pathways representing an ideal service, not taking into account the practicality or affordability of full implementation. In NHS England, where Nice decisions are binding, it is not unusual for Nice decisions to effectively displace services which at a local level have a higher priority. Such an approach would be hugely detrimental and costly locally, inevitably leading to the restriction of more-effective interventions. HSC has worked hard over the last two years to bring its spending under control and to balance the budget but in so doing has not cut, reduced or changed the independent process that determines which drugs are funded locally. Cost and service improvement initiatives will continue, but a decision to make Nice decisions binding in Guernsey would require the States to decide how this would be funded. This would effectively mean an unpredictable annual budget if a new, expensive treatment became available. Regrettably, it is a very sad but harsh reality that in some cases, while a new treatment may offer hope, it may not actually significantly extend life or the quality of life in real terms. As a community we would have to make decisions either regarding what other services should be cut across the Bailiwick, or possible increases in taxation, in order to fund an ever-increasing budget requirement from HSC and ESS.

Particular interest has been shown regarding the drug Ibrutinib. A request for this drug was considered in 2016 which was declined on the grounds of very high cost and unconvincing evidence of short-term benefits. However, since 2016, as well as a significant discount being offered by the company producing this medicine, more mature data regarding its efficacy changed the decision regarding funding. Approval was given and it was added to the prescribing list in February 2018.

Decisions on any investment have to be thorough and detailed. In the case of Ibrutinib, the annual cost to Guernsey of this drug will be in excess of £100,000. Ensuring that this represents value for money as well as being clinically effective is an essential part of the decision-making process.

Without a huge investment in staff, it is not feasible for Guernsey to review all new drugs when they are approved by Nice or when they come to the market. Drugs for rare cancers may never be needed on the islands. Patients move in and out of the system and knowledge does not remain stationary. The Kings Fund Review found four out of every five new cancer drugs funded in the UK via the Cancer Drugs Fund did not benefit patients in terms of lengthening their lives, but exposed them to toxicity.

It is worth noting that in the Channel Island Cancer Report 2017, which compares aged-standardised mortality rates in Guernsey, Jersey and England for 20 specified cancers, death rates are either lower or the same in Guernsey than the south-west of England for 17 of the 20 cancers.

Early detection of cancers is one of the most significant factors in determining outcomes. Guernsey is fortunate to have same-day access to excellent primary care services. The MSG sees suspected cancer patients within two weeks and usually a lot faster. In addition, thanks to the calibre of consultants available in Guernsey, the quality of surgery available is extremely high, which is very important in achieving best outcomes for patients.

Jersey and the Isle of Man do not automatically approve all Nice-approved drugs either – again because Nice guidelines do not take into account the unique health and care responsibilities of an island community as well as the practicality and affordability of full implementation. Indeed, were we to only adopt Nice guidelines automatically it would have meant that we would not have approved Bevacizumab (Avastin) for macular degeneration. This has enabled HSC to achieve the same outcomes at far lower costs than the Nice-recommended therapies. This has made a difference for a significant number of people locally.

Both HSC and ESS have to make difficult decisions every day with regard to drug and drug treatment funding. There are commissioning guidelines in place that are ratified by members of the States. Population-based commissioning is difficult and can be very emotive, but the priority is to ensure clinical effectiveness.