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Last autumn the government announced that the National Institute for Health and Clinical Excellence (NICE) will lose its power to decide which drugs the NHS can and cannot use. NICE will still provide advice on drug efficacy but GP consortia, due to replace primary care trusts from 2013, will decide on local drug funding. The plans will start in 2014 with a new system called ‘value based pricing’, which will be negotiated by civil servants. Although the immediate impact that this decision will have on emergency services is nil or minimal, beware the unintended consequences.
A popular view of NICE is that it has the personality and management style of a control freak and is a mean, penny-pinching government quango denying sick people access to life-saving drugs, a belief promulgated by some media outlets and largely based on emotional stories from cancer patients and their support groups. Since the announcement of NICE's new role, the same media outlets have been generally very pleased to hear it, using a thesaurus of dismissive adjectives (about NICE) in reporting the story, but let's not let the facts stand in front of a good story, namely that NICE has recommended the NHS use 83% of the drugs and treatments it has assessed.
If we return to a basic analysis, who, in their right minds, other than politicians embroiled in the turmoil and frenzy of a general election campaign, will deny that there is rationing in the NHS? If this is accepted, then neutral analysts will agree that the best way to ration drugs is to seek independent advice that is evidence-based, can be defended under cross-examination and is not conflicted by coercive pressure from lobbyists, be they politicians, patients or drug companies; these pressure groups can have their say in a parallel debate on the upper limit of a QALY (quality-adjusted life year), currently about £30 000.
The government believes that prices will now fall, although there is little evidence to support this; it is not difficult to construct an argument to support the opposite view. Whether prices go up or down, the need to ration prescribing will not go away—someone will still have to make hard decisions about what the NHS can afford.
In the brave new world, drug-prescribing decisions will be delegated and governed locally, with discretionary funding from local budgets, but is this a true decentralised delegation or are doctors just being dumped on? Perhaps we should not be too cynical, but is this actually a postcode lottery wearing a new overcoat?
Here are some unintended consequences.
This process will directly expose the GP consortia to lobbying from local pressure groups (will those who shout the loudest get what they want?) and to the presentation of incomplete data from drug company sales teams hired to pedal their employer's wares. If a GP consortium crumbles under such pressure, will others be obliged to follow suit? Postcode prescribing may return with a vengeance.
The future role of GPs may change; if they become the targets of a tabloid media onslaught after deciding not to prescribe a drug to a cancer patient, will they cave in and change their decision? If so, what will happen to their other patients if they blow the budget on a handful with high-profile diseases? What will happen to the budget allocation to other services, both acute and elective? Will the drug budget be ring-fenced or will they just switch costs between cost centres, one losing out to the other?
Will the GPs be held to account for NHS rationing? If so, for how long will they tolerate this responsibility? Will the doctor–patient relationship change from one of trust and respect to a more confrontational one, tinged with resentment and loss of credibility? The unintended consequences can be thought through quite easily without needing an overly fertile imagination.
Perhaps we should not become unduly pessimistic; the Minister of Health believes that ‘we will move to an NHS where patients will be confident that where their clinicians believe a particular drug is the right and most effective one for them, then the NHS will be able to provide it for them’.
Provenance and peer review Not commissioned; not externally peer reviewed.