COVER STORY
“THE NHS HAS A FINITE BUDGET AND AREAS FOR INVESTMENT MUST BE PRIORITISED. NHS BORDERS IS CONCERNED THE CHANGES TO THE SMC PROCESS HAVE LED TO LESS COST-EFFECTIVE DRUGS BEING APPROVED AT THE EXPENSE OF MORE COST- EFFECTIVE TREATMENTS”
the way drugs are assessed for use in Scotland. He is expected to report in the summer.
So has access to medicines improved?
SMC’s mothership organisation, Healthcare Improvement Scotland told the Committee in written evidence that, since making the changes, “SMC has accepted significantly more new medicines for end of life and very rare conditions with an increase of around 40% in the acceptance rate for these medicines.”
In a joint submission NHS Scotland Directors of Pharmacy and the Scottish Association of Medical Directors said: “The new SMC processes, including the Patient and Clinician Engagement (PACE) system, has improved access to 28 end of life and rare diseases medicines that previously may not have been accepted on the basis of cost effectiveness.”
Meanwhile boards appear to have complied with a separate instruction to say “yes” more often to Individual Patient Treatment Requests by
clinicians for medicines that are not recommended by SMC – though oncologists told the Committee that processes and decisions did seem to vary across Scotland.
Some NHS boards are, however, not convinced that saying yes to more medicines is the right thing to do, with several expressing concerns about the impact on the medicines and care budgets.
“The introduction of these processes for end of life treatments seems hard to justify,” NHS Borders said in its evidence. “Why should treatment at this stage of life be prioritised above other life stages and why should different cost effectiveness thresholds apply?” The Board echoed others when it said: “The NHS has a finite budget and areas for investment must be prioritised. NHS Borders is concerned the changes to the SMC process have led to less cost-effective drugs being approved at the expense of more cost-effective treatments.”
Patient organisations expressed a different concern – that important medicines are still being turned down. Breast cancer charities pointed to four medicines for people with incurable secondary breast cancer that were considered under the new system and not approved.
Cross-examined by the Committee, Scotland’s Health Secretary, Shona Robison MSP revealed she has asked that Dr Montgomery consider how medicines submitted to SMC can be offered at the best and fairest price from the start: “The short answer is that we do not always get to the company’s best price first time round, or even at all, although I should be clear that not all the pharmaceutical industry behaves in the same way when it comes to pricing, and although companies are absolutely entitled to make commercial decisions on how they price their drugs, it is incumbent on all of us to ensure that the NHS has systems in place so that the best value is achieved and the need for time-consuming resubmissions to the SMC is avoided.”
Ms Robison said there should be external commercial negotiations linked with the SMC process, adding, “We take the view that there should be external commercial negotiations linked with the SMC process. I think the pharmaceutical industry could also
do better on fairer pricing without impacting unduly on the return for their shareholders. If we get that into a better place then it means that things like the New Medicines Fund will go further, supporting more people in Scotland.
“If a pharmaceutical company is able to offer a better price elsewhere, we would expect there to be no reason why it could not offer that better price to the NHS in Scotland, as well.”
Medicines for end of life and very rare conditions continue to represent the minority, albeit a growing one, of medicines considered by SMC. The new patient and clinician meetings, combined with more new medicines being licensed, have increased pressure on SMC. It is now not unusual for SMC to delay the start of its consideration of a medicine, leading the industry to seek assurances that the organisation has the resources it needs.
Before reaching formularies, SMC’s recommendations are considered by the Area Drug and Therapeutic Committees (ADTCs) of each of Scotland’s 14 territorial NHS Boards.
The Health Secretary explained to MSPs in her evidence that a collaborative group of Scotland’s ADTCs has been established:
“It has led national work on optimising medicines use; it is supporting and strengthening public involvement; and it is developing and testing a new categorisation and communication policy for formulary decisions.”
One contribution to note has been from Dr Andrew Walker, the Glasgow University economist who during his time on the SMC worked hard to try to demystify its processes
In his submission he asked the Health Committee to consider several ‘consensus statements’ to focus the debate. First amongst these was whether one set of national guidance is preferable to 14 local sets.
John Macgill is Director of Ettrickburn, a communications and government relations company specialising in Scottish healthcare and lifesciences.
www.ettrickburn.com
“THE SHORT ANSWER IS THAT WE DO NOT ALWAYS GET TO THE COMPANY’S BEST PRICE FIRST TIME ROUND, OR EVEN AT ALL, ALTHOUGH I SHOULD BE CLEAR THAT NOT ALL THE PHARMACEUTICAL INDUSTRY BEHAVES IN THE SAME WAY WHEN IT COMES TO PRICING, AND ALTHOUGH COMPANIES ARE ABSOLUTELY ENTITLED TO MAKE COMMERCIAL DECISIONS ON HOW THEY PRICE THEIR DRUGS, IT IS INCUMBENT ON ALL OF US TO ENSURE THAT THE NHS HAS SYSTEMS IN PLACE SO THAT THE BEST VALUE IS ACHIEVED AND THE NEED FOR TIME-CONSUMING RESUBMISSIONS TO THE SMC IS AVOIDED”
SCOTTISH PHARMACIST - 15
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