By Leela Barham
The Cancer Drugs Fund (CDF) in England covers the cost of cancer treatments either when the National Institute for Health and Care Excellence (NICE) has said ‘no’, or hasn’t yet come to a view. It started with £50 million ($78 million) and is now £200 million ($311 million) a year. Previously managed regionally, the fund is now the responsibility of NHS England (NHSE), the new national agency tasked with spending some £20 billion and overseeing the Clinical Commissioning Groups (CCGs) who will spend the rest of the over £100 billion NHS budget. NHSE has just released the first data covering the first quarter of financial year 2013/14 on the fund since they took it over.
More drugs covered by the Fund
NHSE has added five new drugs to the CDF list to treat 11 different indications of cancer. And they were added quickly too: NHSE says that they were “added to the national list as soon as they were licensed, highlighting the responsiveness of the new centralised system and an overall increase in the availability of important cancer drugs”.
The CDF now covers 31 products for 74 indications. Over the financial year 2013/14 so far that means 4,128 patients have had their drug funded by the CDF. The top 3 drugs funded are:
· Roche’s Bevacizumab
· Johnson and Johnson’s Abiraterone
· Napp’s Bendamustine
Together they account for just over half of all funding applications.
More patients getting access but not just through the CDF
NHSE are also keen to point out that some of the products previously on the CDF are now part of usual funding in the NHS. It’s not clear which these are, nor whether that was because the Fund enabled new insights into real world benefits of their use.
Some other patients must still use the Individual Funding Review (IFR) process though. This was the default for patients before the CDF came into play for those products that would not be routinely funded, offering them a chance, if their doctor was prepared to support their case, to argue that they faced particular individual circumstances that should merit the NHS paying for them to have a particular drug. NHSE also looks after the IFR policy too these days.
So far for the financial year 2013/14 352 IFRs have been made, 100 approved and 92 refused. The others are still going through the process in some shape or form.
Getting on the new CDF list = evidence + commercial schemes
Partly these new additions reflect review of trial data by the Chemotherapy Clinical Reference Group. Their review led to the additions of: Sanofi’s Aflibercept in 2nd line colorectal cancer, Roche’s Bevacizumab in 2nd line Ovarian Cancer and Roche’s Pertuzumab in breast cancer.
But also undoubtedly playing a role are the confidential commercial schemes agreed with NHSE. That seems to confirm, if we didn’t know it already, just how important NHSE is to both pricing and reimbursement in the new NHS post the April 2013 implementation of the Health and Social Care Act 2012.
New CDF and NICE
What remains to be seen though is exactly how these new CDF funding decisions interact with NICE guidance. Some may suspect that NICE decisions are becoming tougher as the presence of the CDF offers a funding route which may make appraisal committees more comfortable saying no. And as it turns out, commercial schemes (real meaning: a discount) make these products more cost-effective.
Aflibercept in colorectal cancer is still going through the NICE Single Technology Appraisal (STA) process. But NICE is not minded to recommend use based on their Appraisal Consultation Document published in June 2013. Final guidance is expected in October 2013. So too is Pertuzumab in breast cancer, with final guidance expected in November 2013. Just as with Aflibercept, NICE isn’t minded to recommend.
Bevacizumab in Ovarian Cancer has already been appraised with NICE not recommending use in July 2013.
The problem is, and perhaps a perversity of the CDF policy, is would NICE have been so willing to say no if the CDF wasn’t there? And why couldn’t they have said yes if the commercial schemes were available? It’s not clear if they are just not enough to meet NICE thresholds for cost effectiveness or if they weren’t offered up during the NICE appraisal process. All of this makes achieving access more murky in the new NHS.
Speculation continues about the future of the CDF since it was a time limited policy running up to April 2014. However, it was supposed to be a ‘bridge’ to Value Based Pricing (VBP). VBP however remains mysterious and with negotiations ongoing between the Government and the Association of the British Pharmaceutical Industry (ABPI) over the successor to the Pharmaceutical Pricing and Reimbursement Scheme (PPRS), not much is known in the public domain about how VBP, the successor to the PPRS and the CDF will fit together, if at all.
Leela Barham is an independent health economist
You can find out more about on her website:
http://leelabarhameconomicconsulting.blogspot.co.uk and contact her on: firstname.lastname@example.org