We were disappointed to read Professor Clark’s defence of the perceived value of the Cancer Drugs Fund ((CDF); feature article published in the BMJ Sept 11th.)
Since the establishment of the CDF there have been concerns (1, 2) that it would undermine NICE, permitting funding of drugs NICE had not yet appraised, as well as those found not to be cost-effective. Since the announcement of the introduction of ‘value for money’ criteria into the CDF drugs’ evaluation, NICE is not only being undermined, but their technology appraisal process duplicated. We believe NICE would dispute the claim that: “[NICE] have enough [clinical trials evidence] to say whether a drug works, but not how well or what effect it has on the patient pathway” - conveniently, there is no evidence that the CDF can do it better since they have yet to try. Sir Andrew Dillon told MPs it ‘makes no sense’ that medication NICE has ruled as not cost-effective is available through the CDF. Professor Clark’s comments that, “we’ll be working going forwards much better with NHS England and NICE” may not be aligned with Sir Andrew’s request for “an alignment of processes and methodologies”.(3)
Professor Clark asserts that the English public feel that cancer is worthy of greater spend than other diseases based on the following: “[The NICE end of life criteria approach] was never challenged…that told me it was in the psyche of English people and…it reflects something that most people agree with”. This is a very flawed argument which assumes that the public understood the opportunity cost associated with the CDF and realised they were preferentially paying for cancer. It is also arguably false according to empirical research.(4) Every pound spent on cancer drugs in the NHS is not spent on another health good. While Professor Clark may claim the CDF was ‘additional’ money, it would be naive to assume that the £20 billion efficiency savings which are consuming the NHS at present, were unrelated to the now £280 million being spent on the CDF.
While Professor Clark congratulates the CDF for reimbursing medicines only at the lowest price proposed for use in the NHS, he is later quoted conceding that, “some companies have seen the CDF as an easy route to funding…because they [pharmaceutical companies] don’t have to drop the price to get CDF approval.” In our paper,(5) we demonstrated that there is greater prescribing of non-cost-effective drugs in England than Wales (without a CDF), with slower adoption of new cost-effective drugs.
Finally, one of the most lamentable features of the CDF has been the lack of quality data collection to steer future decision-making. There has been no request for quality of life, or patient reported outcome measure data. And no attempt so far to address early evidence that suggested that prescribing of chemotherapy through the CDF was of much shorter duration than that expected from clinical trials.(6)
Our message is this: Where is the evidence? We have found no convincing evidence that the English public value cancer above other serious/life-threatening diseases; no convincing evidence that cancer drugs will prolong cancer survival greater than comparable cancer treatments, such as radiotherapy or surgery, in fact the reverse,(7) and where is the evidence that the CDF has provided invaluable data to improve decision-making in chemotherapy? The public preference for cancer over other diseases and for cancer drugs over other treatments has been assumed and we are left with the question: where else might this money have been better spent?
1. Howell J. Return of the postcode lottery Opportunity cost of the Cancer Drugs Fund. British Medical Journal. 2011;342.
2. Thornton S. Return of the postcode lottery Cancer Drugs Fund is not a fair allocation of NHS resources. British Medical Journal. 2011;342.
3. Knapton S. Cancer Drugs Fund makes no sense, says head of drugs rationing body NICE. The Telegraph. 2014 02 Sept Sect. Health News.
4. Linley WG, Hughes DA. Societal views on NICE, cancer drugs fund and value-based pricing criteria for prioritising medicines: a cross-sectional survey of 4118 adults in Great Britain. Health Econ. 2013;22(8):948-64.
5. Chamberlain C, Collin SM, Stephens P, Donovan J, Bahl A, Hollingworth W. Does the cancer drugs fund lead to faster uptake of cost-effective drugs? A time-trend analysis comparing England and Wales. Br J Cancer. 2014.
6. Stephens P, Thomson D. The Cancer Drug Fund 1 year on--success or failure? Lancet Oncol. 2012;13(8):754-7.
7. Foot C, Harrison, T. How to improve cancer survival, explaining England's relatively poor rates. Cavendish Square, London W1G 0AN: The King's Fund and Cancer research UK, 2011.
Competing interests:
No competing interests
15 September 2014
Charlotte Chamberlain
NIHR Doctoral Fellow
William Hollingworth
School of Social and Community Medicine, University of Bristol
Rapid Response:
We were disappointed to read Professor Clark’s defence of the perceived value of the Cancer Drugs Fund ((CDF); feature article published in the BMJ Sept 11th.)
Since the establishment of the CDF there have been concerns (1, 2) that it would undermine NICE, permitting funding of drugs NICE had not yet appraised, as well as those found not to be cost-effective. Since the announcement of the introduction of ‘value for money’ criteria into the CDF drugs’ evaluation, NICE is not only being undermined, but their technology appraisal process duplicated. We believe NICE would dispute the claim that: “[NICE] have enough [clinical trials evidence] to say whether a drug works, but not how well or what effect it has on the patient pathway” - conveniently, there is no evidence that the CDF can do it better since they have yet to try. Sir Andrew Dillon told MPs it ‘makes no sense’ that medication NICE has ruled as not cost-effective is available through the CDF. Professor Clark’s comments that, “we’ll be working going forwards much better with NHS England and NICE” may not be aligned with Sir Andrew’s request for “an alignment of processes and methodologies”.(3)
Professor Clark asserts that the English public feel that cancer is worthy of greater spend than other diseases based on the following: “[The NICE end of life criteria approach] was never challenged…that told me it was in the psyche of English people and…it reflects something that most people agree with”. This is a very flawed argument which assumes that the public understood the opportunity cost associated with the CDF and realised they were preferentially paying for cancer. It is also arguably false according to empirical research.(4) Every pound spent on cancer drugs in the NHS is not spent on another health good. While Professor Clark may claim the CDF was ‘additional’ money, it would be naive to assume that the £20 billion efficiency savings which are consuming the NHS at present, were unrelated to the now £280 million being spent on the CDF.
While Professor Clark congratulates the CDF for reimbursing medicines only at the lowest price proposed for use in the NHS, he is later quoted conceding that, “some companies have seen the CDF as an easy route to funding…because they [pharmaceutical companies] don’t have to drop the price to get CDF approval.” In our paper,(5) we demonstrated that there is greater prescribing of non-cost-effective drugs in England than Wales (without a CDF), with slower adoption of new cost-effective drugs.
Finally, one of the most lamentable features of the CDF has been the lack of quality data collection to steer future decision-making. There has been no request for quality of life, or patient reported outcome measure data. And no attempt so far to address early evidence that suggested that prescribing of chemotherapy through the CDF was of much shorter duration than that expected from clinical trials.(6)
Our message is this: Where is the evidence? We have found no convincing evidence that the English public value cancer above other serious/life-threatening diseases; no convincing evidence that cancer drugs will prolong cancer survival greater than comparable cancer treatments, such as radiotherapy or surgery, in fact the reverse,(7) and where is the evidence that the CDF has provided invaluable data to improve decision-making in chemotherapy? The public preference for cancer over other diseases and for cancer drugs over other treatments has been assumed and we are left with the question: where else might this money have been better spent?
1. Howell J. Return of the postcode lottery Opportunity cost of the Cancer Drugs Fund. British Medical Journal. 2011;342.
2. Thornton S. Return of the postcode lottery Cancer Drugs Fund is not a fair allocation of NHS resources. British Medical Journal. 2011;342.
3. Knapton S. Cancer Drugs Fund makes no sense, says head of drugs rationing body NICE. The Telegraph. 2014 02 Sept Sect. Health News.
4. Linley WG, Hughes DA. Societal views on NICE, cancer drugs fund and value-based pricing criteria for prioritising medicines: a cross-sectional survey of 4118 adults in Great Britain. Health Econ. 2013;22(8):948-64.
5. Chamberlain C, Collin SM, Stephens P, Donovan J, Bahl A, Hollingworth W. Does the cancer drugs fund lead to faster uptake of cost-effective drugs? A time-trend analysis comparing England and Wales. Br J Cancer. 2014.
6. Stephens P, Thomson D. The Cancer Drug Fund 1 year on--success or failure? Lancet Oncol. 2012;13(8):754-7.
7. Foot C, Harrison, T. How to improve cancer survival, explaining England's relatively poor rates. Cavendish Square, London W1G 0AN: The King's Fund and Cancer research UK, 2011.
Competing interests: No competing interests