England's Cancer Drug Fund Conundrum

Back in October 2014 I asked how do you solve a problem like the Cancer Drugs Fund? It seems the answer lies in a heady mix of delistings, price drops, and extra money to keep within the (supposedly) fixed budget of the fund. It’s due to end in 2016, but then again, it was due to end in 2014 too but got a reprieve.

The fund is controversial because it singles out cancer, and not only that, but English cancer patients only, reflecting the devolved healthcare of the UK. The ring-fenced fund covers medicines that have been rejected by the National Institute for Health and Care Excellence (NICE), not yet appraised by them, or won’t be considered at all by NICE. So far over 60,000 patients have benefitted from the fund since 2010. Critics estimate that at the same time, if the money had been spent elsewhere it could have generated over 17,800 quality adjusted life years.

The fund originally started small; £50 million ($75.8m) in an interim fund in 2010, moving to £200m per year before reaching £280 million ($424.4m) for 2014/15. Now it’s going up to £340 million ($515.3m) for 2015/16. It might have been more except that some companies have dropped their prices and other drugs have been dropped as part of a round of ‘reprioritorization’ undertaken in December 2014 and with the results coming out on January 12, 2015. NHS England, who run the fund, say that the December review has saved £80 million that would otherwise have been spent.

The fund was a political fix, a way to soften the blow of so many NICE ‘no’s’ to cancer medicines. The fix worked for a while, because the fund was underspent and it was easy to ignore those who pointed out that it was unethical for selection cancer patients over others, undermined NICE, introduced the risk of gaming, gave little incentive for lower prices, and fails to address underlying problems.

With the number of drugs, number of patients, and some prices being high, the fund was inevitably going to become overspent. Some, such as the British Oncology Pharmacy Association (BOPA) predicted that early on, it just took some time to come through.

The political fix has however become increasingly fragile. Fifty-nine of the 84 indications that were on the list in December will stay on, the remainder dropped. Patient groups are angry. Pharma companies are ‘outraged’ and intend to appeal. NHS England say that this means there’s headroom for new medicines, adding Panitumumab in bowel cancer, and Ibrutinib in mantle cell lymphoma and Ibrutinib for chronic myeloid leukaemia. Headlines about the latest CDF decisions abound; some supportive, most against – probably not comfortable for the Conservatives who put the fund forward the fund in their Manifesto in the run up to the last General Election.

There are questions that still need to be addressed: What happens to those newly diagnosed patients who can’t access a medicine previously funded, will they be able to get it funded through the exceptional route, pay privately, or go without? Just how does the CDF work when there is an affordability guarantee for NHS spend on branded medicines in the 2014 PPRS? Where are the PPRS payments, worth millions, going? What ever happened to the CDF audit? Did NICE get their decisions right or wrong based on what’s really happened to English cancer patients? And given a General Election in May 2015, will a new Government be brave enough to get rid of the fund and get on with improving NICE, and companies get on with improving the efficiency of their R&D and offer fair prices?

Leela Barham is an independent health economist. You can find out more about on her website and contact her at leels@btinternet.com