The National Institute for Health and Care Excellence (NICE) in England, and the Scottish Medicines Consortium (SMC) in Scotland, face the same challenge of making drug funding recommendations that are fair to all users of the NHS and acceptable to society. Health technology appraisal is a devolved responsibility, so it is possible that the two countries’ decisions will diverge, as each agency need to reflect the preferences of the population it serves. Both agencies have responded to the challenges of appraising drugs to treat rare conditions, and patients in the last months of life, with a series of adjustments to their processes – beginning with NICE’s ‘end of life’ criteria in 2009, and more recently, SMC’s 2014 reforms including the Patient and Clinician Engagement (PACE) meeting.
As part of a study of the 2014 SMC reforms, we reviewed a 2-year cohort of 53 cancer drugs assessed by SMC post-reforms (9/14-9/16), and compared patient access in Scotland and England. The analysis was complicated by the existence in England of two funding streams for cancer drugs: routine NHS funding following recommendation by NICE, plus the Cancer Drugs Fund – a ring-fenced fund for cancer drugs that were not routinely available.
In our original analysis, we identified important divergence between SMC and NICE, with 22 of these drugs being available in Scotland, but not – or not yet – recommended by NICE. This could be interpreted as indicating SMC was at that time providing a more permissive environment than NICE, either in terms of willingness to recommend, or timing. The patient access position, however, was less divergent overall because of the CDF, resulting in a net position of 8 of these drugs available in Scotland only, and 6 in England only (CASMI, 2017).
What has changed since September 2016? In the past year, we have seen important convergence, with the number of drugs showing differential access reducing from 14 to 10. Five of these are due to a No from one agency (4 of which are SMC) – the others are pending at NICE, not referred to NICE, or non-submissions by the company.
More interestingly, following the CDF reforms in England from July 2016, the number of these drugs ‘rescued’ by the CDF has dropped dramatically from 17 to 6, as CDF drugs moved into routine commissioning in England following positive recommendation by NICE. Of note, this includes 9 drug/indication combinations that NICE had previously Not Recommended.
The access picture, then, is more similar than a year ago – not only in terms of access, but also structurally. Both agencies (particularly NICE) have revised previous Not Recommended decisions, and the number of disparities has reduced, with pending decisions at NICE that could continue the convergence. Perhaps more importantly, the mechanism of funding – through routine commissioning – is increasingly consistent between England and Scotland.
What does this tell us? Can we conclude that neither agency is fundamentally more permissive, and the differences we’ve seen are pendulum swings as each country in turn adjusts its process – that is, differences in preferences and willingness to pay between the countries are actually minor? Or, has each country simply driven a different commercial deal that it can accept, and the apparent convergence is due to industry’s pricing flexibility in order to supply products to patients in both countries? Either way, the reduction in disparity between the countries is most welcome.
– Dr Liz Morrell