The Cancer Drugs Fund (CDF) – introduced by the Coalition in 2010 – is to undergo significant changes, receiving an increase in overall funding but seeing many drugs currently available removed from its list. The very existence of the fund is a point of controversy, but its reform brings into clarity the relationship between public health bodies and the private firms profiting from the provision of medication. Here are seven reflections on what the reform of the CDF clarifies about the relationship of the NHS and Big Pharma:
1. Without the CDF, thousands would not have had access to drugs that can improve and extend their quality of life.
Since its launch in 2010, around 55,000 cancer sufferers have received medication funded by the CDF. When re-evaluating the CDF in 2012, Care Minister Paul Burstow lauded it for “making a difference to the lives of thousands of people with cancer.” The CDF provides funding for medication that the National Institute for Health and Care Excellence (NICE) has deemed either too experimental or expensive for provision through the main NHS funding channels.
2. The very existence of a specialist fund for cancer drugs highlights the failings of the current relationship between the NHS and pharmaceutical companies.
The fund itself has been strongly criticized. For Karl Claxton, professor of health economics at York University, it provides guaranteed high prices to Big Pharma: “The fund has done more harm than good for NHS patients,” he writes, and the money would be better spent increasing the budget of the NHS across the board. For Claxton, the money spent on the CDF would be better used across the NHS as a whole, adding to the overall budget rather than funding specific treatments for one category of illness.
3. Is the CDF really to blame for Big Pharma’s profits?
Whilst there can be no doubt that the CDF consolidates the opportunity for profit-making by Big Pharma, it seems disingenuous to suggest that if the CDF did not exist, this problem would evaporate. Across the board, the average profit margins of pharmaceutical companies are higher than those for any other sector, including banking.
Against this wider context, the CDF’s £200m per year makes for a fraction of Big Pharma’s profits. The problem, then, is not with the CDF itself. Providing medication that can extend the lives of patients is an important goal, and one that should be at the heart of the NHS. The problem instead lies with Big Pharma itself, effectively making grotesque profits from over-charging public money.
4. The logic of the market has colonized healthcare narratives.
The entire sphere of debate over healthcare has been relentlessly hounded, for decades, by a narrative of cost effectiveness. Such a discourse treats healthcare as a business just like any other. Efficiency-savings, streamlining, and the dreaded ‘reform’ – common enough now across the public sector – are just as likely to be heard in the context of healthcare provision.
Within the terms of this narrative, human lives – and indeed the days and weeks by which they might be extended – become values to be weighed and balanced against the financial cost of their provision.
5. Healthcare professionals see real benefits of some CDF-provided drugs, and definitions of ‘effectiveness’ are controversial.
The arguments of Claxton and others rest on the suggestion that the majority of medication provided by the CDF is relatively ineffective. Yet the very definitions of both medical and cost effectiveness are contested and in some instances begin to wilt under sustained scrutiny.
In part, this is about how NICE defines the terms of the evidence it considers. Take Avastin, one of the most commonly-applied for drugs on the CDF, used by sufferers of both bowel and breast cancer, and now removed from the list of drugs covered by the CDF. As Harpreet Wasan, a leading consultant oncologist, puts it:
“NICE has relied on clinical trials which look at the average life expectancy of patients who have been given a particular medication. The problem is that, as common sense should tell us, no patient is ever average. Some who take part in trials may die regardless of treatment, contributing to a drop in the average life expectancy associated with the drug. NICE has used this method to claim Avastin extends life by just six weeks. While this may be statistically true, what about those who respond favourably and go on to live for many months and even years after treatment? They are ignored by NICE’s unnecessarily black-and-white approach.”
A single course of Avastin costs £20,800, and is freely prescribed in Italy, Germany and France, as well as Australia and Canada outside Europe. Some of the most recent scientific research has suggested that Avastin, as part of a wider chemotherapy regime, has a “small but significant effect” on overall average survival rates, with significant benefits for some patients. But against the rhetoric of cost-effectiveness, such benefits are insufficient to earn it the full support of the NHS.
6. Big Pharma is profiting. So we should make them our target, not the CDF.
Critics of the CDF often buy into the rhetoric of cost-effectiveness themselves. Rather than calling for these medicines to be made more affordable and incorporated into the mainstream NHS, or indeed attacking the pharmaceutical companies who are profiting, they charge the CDF with exaggerating Big Pharma profits.
This is to put the cart before the horse. The profits exist because of Big Pharma’s utter dominance of healthcare and the complete failure of governments to challenge their profit-making motives. In this sense the CDF was an imperfect attempt to provide access to some important medication that was beyond the mainstream NHS budget.
These drugs can and do improve and lengthen the lives of some patients. Life-extending drugs like Avastin should not be made inaccessible to those unable to afford private medical care.
7. The battle against Big Pharma isn’t being won because it isn’t being fought.
The weakness of existing criticisms are that they fight on the wrong battleground. Although the state can rightly be criticized for its role in the marketization of healthcare provision, the real target in this case ought to be Big Pharma.
There is a lesson to be learned from the late writer and activist Mike Marqusee. It is one of the great tragedies of history that in the same week as the reforms to the CDF were announced, Marqusee lost his life to multiple myeloma, a bone marrow cancer.
In The Price of Experience: Writings on Living with Cancer, he includes a piece originally written in 2010 where he writes of his joy that “extra money for new expensive life-extending cancer drugs will benefit thousands more, including me.” Yet in the same piece, he lampooned the government for making real terms per capita cuts to NHS funding, also pointing out that the government’s own reorganization of the NHS is projected to cost £3bn, or around 5 times the cost of the CDF.
When it came to the question of the availability of drugs, Marqusee was clear about where the blame lay: “exorbitant drug prices are at the root of recent controversies over … ‘expensive drugs’.” Our critique must begin at the door of Big Pharma, not policies like the CDF which, however imperfectly, try to allow access to medication that Big Pharma itself makes unaffordable.