Editor—We had understood that one of the intentions of the National Institute for Clinical Excellence (NICE) was to rationalise the introduction of new drugs and technologies across the United Kingdom so that NHS patients would have equitable access. This has plainly not happened. We illustrate the problem with three recently licensed drugs, imatinib, irinotecan, and trastuzumab.
Imatinib has yet to be appraised by the National Institute for Clinical Excellence, but our local haematologists completed the paperwork for approval by Lothian Health Board's drug evaluation panel. The drug was not approved. Shortly afterwards the Scottish Medicines Consortium issued guidance to indicate that it should be made available: we await the result of an appeal to the drug evaluation panel. Meanwhile patients in Fife can get it.
Irinotecan was approved by the National Institute for Clinical Excellence and the Health Technology Board for Scotland. However, the drug evaluation panel for Lothian has rejected it—despite knowing the decisions of the institute and the board—on the grounds that the improved survival does not justify the cost. If the patients live in the west of Scotland, however, they can receive it. In Aberdeen doctors are allowed to prescribe it but without any additional funding, so that expenditure on irinotecan competes with that on other drugs.
Trastuzumab was approved by the institute after a year's deliberation, and then by the Health Technology Board for Scotland. It is already available in the west of Scotland; but recognising that the real decision about its availability in the east of Scotland lies with the Lothian Health Board, we have to carry out a detailed assessment of the total cost before applying to the drug evaluation panel. The only reason we have any optimism about its decision is that some funding may already have been identified.
The current system seems no more equitable than previously; extra layers of central committees exist, and drug availability continues to depend on local health board decisions. We would advocate a streamlined approach, with centralised decision making bodies such as NICE and the Scottish Medicines Consortium. Any decision in favour of a new drug should result in automatic top-sliced funding going direct to the departments dispensing the drugs, so that clinicians do not have to apply locally for approval and funding.
The alternative is a return to the old system of postcode prescribing. This, however, would require politicians to acknowledge that local health boards have the right to set different priorities and are prepared to take the clinical consequences of their decisions.