David Taylor, Emeritus Professor of Pharmaceutical and Public Health Policy at University College London (UCL), on why recent decisions regarding the Cancer Drugs Fund are blind to our national interests and are insensitive to vulnerable patients.
Over the past century life expectancy across the world increased by about thirty years in rich and poor countries alike. This is the result of better living conditions combined with medical and pharmaceutical advances.
The first great wave of progress was in controlling infections. In countries like the UK, this has not only cut infant and child death rates from conditions like measles and whooping cough, but also mortality from adult-killers, such as influenza and pneumonia and conditions like rheumatic heart disease and stomach cancers caused by the bacterium Helicobacter Pylori.
The next great step was in the field of preventing and treating vascular disease. The overall age-standardised death rate from myocardial infarctions and strokes in this country is now down by over two-thirds compared to the 1950s. This is due to a drop in the number of smokers and advances in medicines, ranging from diuretics and beta-blockers to ACE inhibitors and statins. This is one of the most remarkable achievements in the history of public health.
We could still make much better use of what are now minimal cost off-patent medicines as agents of primary prevention, such as anti-hypertensives. Nevertheless, the control of vascular disease has been the main factor in increasing “rich nation” life expectancy at birth, up from 70 years at the start of the 1980s to over 80 years today.
The most important current wave of health improvement relates to the cancers, the last of the great traditional killers of children and adults — we are now at a very special stage in this wave. The age-standardised mortality caused by neoplastic disease in both North America and Western Europe has declined by almost a quarter since 1990. For individuals aged under 60, age-standardised cancer death rates have in fact halved compared to those recorded at the start of the 1970s. There is good reason to hope that cancer deaths in people aged under 80 will by and large be a tragedy of the past in the UK by the 2050s.
In an area as complex as oncology no single breakthrough will cure cancer. But, provided adequate investment in primary (early detection) and secondary (curative treatment) prevention through to continued improvement in therapies for late-stage disease, fundamental advances against this ”emperor of all maladies” can be expected with increasing certainty.
Seen in a fragmented, ill-informed way the cost-effectiveness of single anti-cancer innovations used to help patients who are close to the end of their lives often seems very limited. Yet viewed holistically, improvements in cancer prevention and treatment sufficient to effectively eliminate the suffering and premature death it causes will generate welfare gains far in excess of the $1,000 billion currently spent worldwide on pharmaceuticals of all types, let alone the $90 billion present cost of anti-cancer drugs.
To put the latter in context anti-cancer drug spending represents little more than 0.1 per cent of world GDP. It is highly affordable when compared to the two per cent of world GDP spent on alcoholic beverages. Likewise, only about one per cent of total NHS costs are accounted for by anti-cancer pharmaceutical outlays, while overall drug costs have not risen markedly as a percentage of all NHS spending for several decades. Falls in the prices of high volume medicines as they become generic largely compensate for spending on much smaller volumes of (temporarily) expensive innovations in areas such as oncology.
Hence, for me, the messages recently given out by NHS England in curbing the availability of anti-cancer medicines via the Cancer Drugs Fund (CDF) it now controls are profoundly disappointing. Regardless of the specific products involved, they betray a mind-set that is insensitive to the needs of significant numbers of vulnerable individuals and families and blind to our national interests in innovative industry and continuing bio-scientific progress.
NHS England was established by Andrew Lansley to insulate NHS decision making from political pressures, and free it to pursue health gain as cost effectively as possible — this is in some ways a laudable aim. But if insulating the NHS from political pressure means making it insensitive to democratic pressures, which favour making special efforts to address special problems like cancer, and leave behind those with metastatic disease (because keeping them alive is considered just too costly), the creation of NHS England could yet prove a mistake for, not only for the Cameron government, but for the people and families the health service should be able to help when they are most in need.
Medicines alone are rarely the answer to any health problem, and no-one wishes to support unfair profits being made from people with potentially fatal illnesses. That is why we need mechanisms like those embodied in the Pharmaceutical Price Regulation Scheme (PPRS). But the British public does not support the NHS only to be told that patients cannot access the best treatments available for conditions, such as advanced breast or prostate cancers, when they need them. If Scotland can do better in caring for cancer sufferers with real sensitivity then it is hard to see why England cannot follow. Hopefully the party that wins the May election will learn lessons from the present CDF shambles and seek to build a system of cancer prevention and care funding that is genuinely fit for human purpose.
David TaylorEmeritus Professor of Pharmaceutical and Public Health Policy, UCL