CANCER AND UK TREATMENT PURCHASING ARRANGEMENTS
The proposed new UK treatment-purchasing arrangements will mean that one group, GPs, will be both purchasers and providers, with a second group, the specialist care sector in hospitals, being purely providers. It will mean GP consortia will have a financial vested interest in keeping patients out of hospitals, which may or may not be a good thing. On the other hand, they will have to justify to their own patients, in a way that the current PCTs do not, why they have chosen to refuse funding for certain treatments, as inevitably they must. It remains to be seen whether the possibility of lower management costs translates, as the government hopes, into better frontline care, as it is not immediately clear to me why GPs are the best people to decide on specialist care choices.
The cumbersome decision-making process in the UK also tends to delay uptake of new cancer drugs and reduce overall spending compared to other similar European economies. Although not formally published, it is estimated that NICE has a target spend of up to £30,000 per quality-adjusted life year gained, treatments costing more being denied funding. Other countries have less formalized methods, but appear to informally apply higher cut-off levels. Currently, the UK spends around 60% of the levels reached in countries such as France and Germany on cancer drugs as a result of this lower cut-off point. This difference seems to be particularly focused on cancer therapy as no such disparity exists in other specialisms such as cardiovascular disease or psychiatry, two other big-spend areas. This is well illustrated by the patterns of spending on sunitinib in kidney cancer since licence in 2006, with the UK showing a late, slow rise in spending on the drug compared to the EU average and Italy, France, Germany, and Spain in particular (Figure 1). It cannot be a coincidence that the relatively poor cancer outcomes seen in the UK compared to our European neighbours occur in a country with a relatively low spend on cancer drugs and big disparities in spending per patient by post-code.
The future trends in spending also look challenging. There are currently 77 drugs licensed in the UK for the treatment of cancer (this ignores drugs for supportive care). Around 25 of these were licensed 1995–2005. There are an estimated 50 drugs seeking approval in the period 2007–12. Clearly, not all of these drugs will succeed in jumping the final hurdle. Furthermore, many will offer only very small gains over alternative treatment options. Some of these drugs, possibly many, will, however, offer big further gains. In addition, there will be the ongoing trend of existing new expensive drugs migrating to earlier disease settings and larger markets as illustrated for Herceptin in breast cancer. All of this will undoubtedly put further heavy financial pressure on all health economies. Until recently, this was only a topic of interest in the UK due to our relatively poor access to new drugs. Increasingly, even US speakers, with previously apparently bottomless health budgets to draw upon, have started to discuss affordability of new therapies. The healthcare reform package of Barack Obama has also put this same issue solidly on the mainstream political agenda in the USA.