Management of drug budgets

Editor—As the local neurologists implementing the introduction of new drugs into neurological practice we take issue with the process described in Beard et al’s article about systems and strategies for managing the drugs budget in Glasgow.¹ We recognise the importance of pragmatism and sound economic analysis in meeting the challenge of increasing drug costs to the NHS. However, we have no confidence in the methods currently implemented by the Glasgow area drugs and therapeutics committee in the assessment of new drugs.

It was made clear to us that if we did not participate in “pragmatic outcome studies” our patients would not have access to new treatments. For this reason we reluctantly agreed to provide limited reports to the drugs and therapeutics committee. These studies have been open label, uncontrolled, and of small numbers of patients. The criteria for assessing sufficient cost effectiveness, which the committee requires to justify subsequent funding, were not defined or explained to us at any stage. At best these studies might produce grade 4 data (as defined by United States Agency for Health Care Policy and Research²).

We regard it as crucial that the responsibility for funding decisions is seen to lie where it does, in fact, lie. The current strategy whereby “if hospital specialists cannot show that a treatment provides measurable and worthwhile benefit it will not be purchased” has the effect of shifting perceived responsibility for funding decisions away from the purchaser towards the clinician. We do not disagree with the concept of cost benefit or cost utility analysis (in distinction to cost effectiveness analysis) in evaluating new drugs, and would take part in such studies if they were adequately resourced and constructed in a manner that would produce new and useful data.

We cannot endorse Beard et al’s view that other health boards should follow the example of Glasgow—an example that the authors themselves recognise may lead to “postcode prescribing.” Beard et al’s paper shows the urgent need to advance national policies for introducing new drugs into clinical practice. We trust that such policies will begin to emerge with leadership from the Department of Health, the royal colleges, specialist societies, and the National Institute for Clinical Excellence. Such guidance should promote equity of access to treatment, appropriate use of drugs, and scientifically sound economic analysis of benefit.