‘Difficult decisions now have to be made’ on health

Since May 2016, with the new committee and senior management structure in place, steps have been taken to control expenditure within health and social care services. For example, expenditure on agency staff was significantly reduced by filling vacancies with substantive staff and off-island complex placements costs were reduced by deploying staff and services on-island to enable service users to be brought home again.

HSC has successfully managed to bring its spending under control without cutting any of its current services. However, this cannot continue. Difficult decisions now have to be made.

Responsibility for, and the funding of the provision of medicines is split between HSC, which pays for medicines used within its facilities, and the Committee for Employment & Social Security (ESS), which is responsible for those prescribed for use in the community.

While recognising the impact of decisions on individual islanders, both committees seek to ensure limited resources are used fairly and equitably, maximising the value of care delivered to the population as a whole.

Difficult decisions had to made regarding the funding of drugs and treatments around 2008/09. The then Drugs and Therapeutics Committee concluded that the Bailiwick couldn’t afford to provide everything that was being recommended in view of the global financial crash and decisions regarding zero-10.

However, it should be noted that HSC or ESS still fund most requests for approved drugs or treatments that are for routine care. HSC policy also aligns to the same Q ALY (Quality Adjusted Life Year1) of £30,000 which Nice applies as its guide in most usual cases. Where things vary is in terms of the fact we do not have an end of life premium (which is a maximum of £50,000 per QALY), a Cancer Drugs Fund or NHS England Commissioned Services for Rare Diseases.

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. Indeed, 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. 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.

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.

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.

Both HSC & ESS have to make difficult decisions every day with regard to drug and drug treatment funding. Population-based commissioning is difficult and can be very emotive, but the priority is to ensure clinical effectiveness.

Health care is constantly moving, with scientific research providing alternative solutions on almost a daily basis. As precision medicine develops, we know more about how a person’s genetics, environment and lifestyle can help determine the best approach to prevent or treat a disease. For example, the recent announcement that genetic testing can determine whether chemotherapy is appropriate treatment for certain types of breast cancer. It has been reported that 70 per cent of women with the most common form of breast cancer could be spared the ‘agony of chemotherapy’.

In December 2017, HSC published its policy letter on the future provision of health and care in the Bailiwick – ‘The Partnership of Purpose’. This was unanimously approved by the States. It contained financial modelling that suggests real-terms public spending on health and care will increase from £193m. to £214m. by 2027 if nothing changes in the way that health and care is provided.

Even with fundamental transformation, there is still likely to be a significant funding gap amounting to millions of pounds per annum as a result of an ageing population, medical inflation and high expectations.

We are already seeing it happen – winter pressures this year have been unprecedented and impacted not just the hospital, but also our community services. St John has seen an increase in demand. Other partner services have reported growing demand. This is the reality of the situation we face.

HSC is reviewing health priorities for the island as quickly as it can and these have commenced this political term.

The first Public Health Needs Assessment is a key transformation priority for HSC in 2018. A project board has been established and met to agree the terms of reference and the scope of the first of a suite of strategic needs assessments. This will be the start of ongoing and continuous reviews of health priorities for the Bailiwick.

HSC is determined to provide fairer access to primary care. It is a key principle of the Partnership of Purpose and is a priority area for us for the rest of this term. We don’t want people put off going to the doctor because of the cost and the truth is, survival of diseases such as cancer is much more improved through early diagnosis than drugs. It too will come at a cost, but long term should help improve sustainability and outcomes.

So, should we be putting money into making primary care free at the point of delivery, or increasing the number of drugs available? Or both? This is the debate we now need to be having and to ask ourselves, if we want to continue to have a health and care service that results in an average life expectancy in the top 10 in the world. This is why the Committee for Health & Social Care is seeking to amend the P&R Plan this week to provide assurance that the current policy will be reviewed this political term.

Deputy Heidi Soulsby

President, Committee for Health & Social Care

1. The quality adjusted life year (QALY) is a generic measure of disease burden including both the quality and the quantity of life lived. It is used in economic evaluation to assess the value for money of medical interventions - www.wikipedia.org.