18 May 2016
Article by Philippa Watkins, National Assembly for Wales Research Service
This article is taken from ‘Key issues for the Fifth Assembly’, published on 12 May 2016.
Is there a postcode lottery when it comes to NHS drugs funding, or are the right processes in place to ensure Welsh patients have fair access to the most effective treatments?
Cases of patients being unable to access certain medicines on the NHS are often highlighted in the media. Politicians may also be aware of constituents who have faced difficulty accessing what they, and their doctor, feel is the most appropriate treatment for them.
It is an emotive and difficult issue. With a limited budget and rising demand for services, NHS Wales will be under increasing pressure to demonstrate that it is prioritising effectively and delivering value for money. Welsh patients want clarity and certainty about treatments and, importantly, to feel they are not subject to a postcode lottery.
Appraisal of medicines
Before new medicines can be routinely used to treat NHS patients, they undergo an appraisal process to determine whether the benefit to patients justifies the cost.
The National Institute for Health and Care Excellence (NICE) advises the NHS on both the clinical and cost effectiveness of some newly-licensed medicines. This advice has a statutory basis
in England and Wales, with Welsh health boards legally obliged to fund NICE-approved medicines.
The All Wales Medicines Strategy Group (AWMSG) has a remit to appraise new medicines that are not on the NICE work programme. Health boards in Wales also have a legal requirement to fund medicines approved by AWMSG.
Cancer Drugs Fund
In England, the Cancer Drugs Fund routinely funds a number of cancer medicines not generally available on the NHS.
Throughout the Fourth Assembly, the Welsh Government resisted calls for a similar fund. It argued that it discriminates against other health conditions, and said that the fund has not resulted in English patients having better access to new, cost-effective medicines than Welsh patients. In 2013 the First Minister stated:
… we know now that the cancer drugs fund is nothing more than a confidence trick. I will explain why I say that. Of those who apply for funding to the cancer drugs fund, more than 70% are refused. For the equivalent in Wales, the individual patient funding requests, which are open to people with all conditions, not just those with cancer, more than half of the applications are accepted.
Individual patient funding requests
If a particular medicine has not been approved by NICE or AWMSG for routine use within NHS Wales, a clinician can make an Individual Patient Funding Request (IPFR) to a health board. Requests are considered on the basis of ‘exceptionality’. An all Wales IPFR policy was published in 2011 to support a consistent approach to decision-making.
There has been continued criticism of the IPFR process. The Fourth Assembly’s Health and Social Care Committee’s 2014 cancer inquiry heard that health board IPFR panels might take different approaches to these requests, and recommended that a national IPFR panel be established to ensure consistency and equity across Wales. A Welsh Government-commissioned review (published in 2014) made a number of recommendations to strengthen the IPFR process, but did not propose moving to a single, all-Wales IPFR panel.
Changes to the Cancer Drugs Fund
A new operating model for the Cancer Drugs Fund will be introduced in England in July 2016. The fund will be brought under the remit of NICE, and should provide patients with earlier access to new drugs and more certainty about which treatments are available. NICE and NHS England have been clear that it will be up to the devolved nations how they respond to the new Cancer Drugs Fund arrangements. It is not yet clear how the changes might affect Wales.
NICE will be appraising a greater number of drugs, at an earlier stage. This in itself might have an impact on AWMSG’s work programme, or on NHS Wales’s medicines budget given the requirement for health boards to fund medicines approved by NICE.
In England, under the new model, drugs receiving a draft recommendation for routine NHS commissioning, or a recommendation for use within the Cancer Drugs Fund, will be made immediately available to patients and will be funded on an interim basis by the Cancer Drugs Fund. Cancer Research UK is calling for clarity on what the changes will mean for patients in the devolved nations where there is no similar funding mechanism to manage conditional access.
The All Wales Therapeutics and Toxicology Centre has established a potential funding pathway for some new treatments in Wales. The ‘One Wales’ process will allow for interim commissioning of medicines for specific cohorts of patients, which will be conditional on manufacturers committing to engage in a subsequent appraisal by AWMSG or NICE. It is envisaged, however, that this process would not be used often.
Regardless of the changes in England, Welsh patients and other stakeholders will want to be confident that the system of appraising and funding medicines is robust, transparent, and promotes fair access to effective treatments in Wales.
- All Wales Therapeutics and Toxicology Centre, Improving access to medicines for Patient Cohorts – ‘One Wales’ Interim Commissioning Process (PDF 204 KB) (2016)
- Cancer Research UK, Changing the Cancer Drugs Fund: a step towards fixing how the NHS provides the best medicines (2016)
- Health and Social Care Committee, Inquiry into progress made to date on implementing the Welsh Government’s Cancer Delivery Plan (2014)
- National Institute for Health and Care Excellence, Cancer Drugs Fund new process information (2016)
- National Institute for Health and Care Excellence/NHS England, Consultation on proposals for a new Cancer Drugs Fund (CDF) operating model: Q&A (PDF 263 KB) (2016)
- National IPFR Review Group, Review of the Individual Patient Funding Request Process – Report for the Minister for Health and Social Services (PDF 539KB) (2014)
- NHS England, Cancer Drugs Fund Consultation (2015)
- NHS Wales, All Wales Policy – Making Decisions on Individual Patient Funding Requests (IPFR) (2011)