Sorry – how is NICE actually the first step to dismantling the NHS, since the reforms the coalition were putting forward was effectively putting the decision about the use of treatments in doctors’ hands, not that a single body (NICE).

Indeed, since the NHS is about free treatment when needed, surely it is arguable that NICE is against the spirit of the NHS by arbitarily (i.e. not on a specific doctor’s advice) withholding treatment. Remember, NICE was not originally part of the NHS, so is clearly not integral to the organisation.

Which is not to say the Daily Mail is well-informed or accurate on this story, just that your political point is not actually that logical.

Just wait for when NICE is no longer arbitrating on this kind of thing and Doctors are having to tell patients that they would love to be able to prescribe this drug, but at £70K a year they can’t afford it. We’ll have stories like this all over the national and local media on a daily basis, except this time it won’t be NICE in the firing line but individual doctors. Doctor / patient relationships will suffer dreadfully.

NICE perform an important service. They decide in a fair evidence based way when a drug is too expensive to be prescribed on the NHS and save the doctor from having to make this awful decision.

Indeed, since the NHS is about free treatment when needed, surely it is arguable that NICE is against the spirit of the NHS by arbitarily (i.e. not on a specific doctor’s advice) withholding treatment.

That rather presupposes that individual doctors are best placed/equipped to evaluate the evidence for the efficacy and cost-effectiveness of particular treatments, an assumption that is far from borne out by empirical evidence.

To dismantle NICE would allow private drug companies to supply drugs without proper financial scrutiny thus opening the Market to abuse and monopolisation. This in turn would lead these companies to have too much bargaining power with the NHS introducing ever more privatisation and voilà post code lottery treatment !!

Boring concerned troll “Which is not to say the Daily Mail is well-informed or accurate on this story, just that your political point is not actually that logical.”

Yes it is, the point being that the private sector IE the drug manufacturers are using the right wing media and lying sacks of shit to attack parts of the NHS. Sorry that is too complicate for you.

All you do is play your concerned trolling that always puts the right wing agenda first. In case you have not noticed this is a left leaning site so we are not interested in Daily Mail liars, and NHS destroyers..

1. Watchman

Sorry – how is NICE actually the first step to dismantling the NHS, since the reforms the coalition were putting forward was effectively putting the decision about the use of treatments in doctors’ hands, not that a single body (NICE).

The drug bill currently costs about 10% of the NHS budget. More and more drugs are being developed (ever wondered why governments keep talking about investing in biotech?) and they are getting more and more expensive. Something has to keep costs under control. NICE is a rationing body, but it does so using evidence, and it has a highly skilled team to make those decisions.

Anyway, the decision over treatments is not being given to the actual GP who is sitting opposite you in the surgery, it is being given to the GP consortium. The GP will say “I think you should have X” but if the consortium has not approved it then you will not get it. There is no appeal unless you have cancer in which case you will be able to appeal to Cameron’s Cancer Fund. But this fund is fixed, so if you happen top have cancer when the fund is exhausted then that’s your tough luck. With a NICE decision you have a guarantee. But poor you if you happen to have cardio-vascular disease (the biggest killer in the country) because Cameron says you are not worth a separate fund.

Do you now see why many people say that the government’s plans are half-baked or just plain nasty? They seem to be designed to fail.

Indeed, since the NHS is about free treatment when needed, surely it is arguable that NICE is against the spirit of the NHS by arbitarily (i.e. not on a specific doctor’s advice) withholding treatment.

No, it is not arbitrary, it is evidenced-based, and by being a national body it also makes sure that there is no postcode lottery where certain drugs are only available in some areas.

The whole of Lansley’s system seems designed to fail. Lansley intends to change the current law so that people can register with any GP anywhere in the country – ie, you do not have to have any geographical connection with the GP. (How will you get out of hours treatment? Good question. It just shows how half-baked the plan is, because Lansley is planning a 24/7 out of hours service for people who do not live near to their GP. Sounds expensive at a time when there are vicious cuts in the NHS funding? Too right! Is this nuts? Yup, like all of Lansley’s plans.) GP consortia will have to decide whether they will approve a treatment. That is, when a new drug is released, they will have to make an evaluation. We do not know how many consortia there will be (Lansley hasn’t a clue and does not care), educated guesses suggest 80, but there could be as many as 500. That could mean 500 evaluations across the country when before there was just one expert – NICE. There could be many different decisions and this could mean that people re-register with a new GP just so that they can get a specific treatment. Healthcare tourism within England. Is that equitable? How will GP consortia be able to plan when they do not know how many patients they will have?

Lansley has also said that GP consortia that go into debt will not be bailed out. This means that as their finances change (say patient with a rather expensive condition registers) then the consortium will have change their prescribing decisions so as to make sure that the books balance. The healthcare tourism of one person (or an innocent change of employment and move of accommodation) could affect many other patients. Is that fair?

6 ‘at a time when there are vicious cuts in the NHS funding?’

Until you said this – then maybe your arguments had validity. No one believes this ‘viscous cuts’ narrative as the budget for the NHS is greater year on year.

@ Watchman

The NHS is not “about” free treatment when needed.

It’s an incredibly complex, ambitious, progressive and admirable scheme to ensure that, through general taxation, the health of the nation is maintained in a system that balances equity, efficiency and effectiveness within finite economic parameters.

NICE became essential to the NHS when we realised a postcode lottery was vitiating the purpose of the service – to provide healthcare to all, regardless of ability to pay. It has been an immeasurable success in ensuring that in a time where the NHS is under huge pressures – an ageing population, growing obesity levels, huge public expectations and increasingly rapacious pharmaceutical companies (with the age of the blockbuster in decline, they are shoving up the prices of their biologics and orphan drugs) – we can maintain a service funded through general taxation that is free at the point of access.

You use the word arbitrarily without understanding its meaning. NICE’s purpose is to ensure that no drug is ever arbitrarily withheld or withheld because of the poverty of a community or the incompetence of a GP in managing their individual budget (and if you don’t believe GPs can be financially incompetent, you don’t know any of the folks I went to UCL Medical School with). NICE’s purpose is to ensure that drugs are allocated judiciously and fairly, without bankrupting the system as a whole.

Yours,

Imran

‘Postcode lotteries’ should be a major line of attack on the Coalition in my view. Labour need to be hammering the point that what their ‘localism’ and ‘decentralisation’ and ‘giving power back to the people’ amount to is an increase in lotteries of just this sort. That’s a message that will resonate with the Daily Mail brigade as much as everyone else; it’s a way to reclaim ‘fairness’, and a way to make the case for the role of (horrors!) the state in ensuring that everyone, everywhere has access to the same high standard of services. In other words, it’s a way of starting to define the ‘centre ground’ in broadly left-wing terms.

I have an older friend (about 80) who suggested that NICE’s policies were wrong because they could eventually have stopped him from receiving treatment for pneumonia and thus dying. He’s an intelligent man, perfectly literate in economics, but clearly in this case his thoughts were ruled by emotion. Even with a month’s hospital stay, the cost of treating pneumonia is small in comparison to that of these “life-prolonging” cancer drugs, and worse when you consider that an 80 year old person could live another decade after recovering from pneumonia, but some cancer drugs provide just an extra couple of months at best. There is also very little awareness that the NHS is still providing cancer treatment and prolonging life with existing – but cheaper – medicines that are slightly less effective, and not simply abandoning patients to their fate.

When even an intelligent person confuses the issue at its most obvious, we need a body like NICE to prevent emotional responses from deciding how best to spend NHS money, and when cost is too excessive for the returns. I thought this government wanted to cut waste and make public services more efficient? Well, there it is, in the starkest terms possible.

The headline is unfortuante. It evokes armies of Mail journos, throwing pills and syringes at hospitals.

Beware ambiguity.

Well it’s been a long time since I was in a lab but monoclonals were, even then, a complicated but basic technology. One has to ask, then, why Avastin is so expensive? I know there can be all sorts of problems but these days one should be able to clone something so important into an organism that allows cheaper production. Is it the purification? I stand ready to be corrected but it seems there’s a bit of profiteering going on.

The neo-liberal government is keen to line corporate pockets as usual, glad to see you covering this.

Big pharm uses monopoly and patents to rack up profits and make the sick pay £bns.

What if my doctor can be reached?
A friend or a fellow lodge member could plead for these drugs by applying emotional pressure. I would not suggest that a backhander could ever be the motivation. Not a doctor surely.
When my turn comes for more routine drugs will they be there, or will the annual budget be running thin?
What I am really asking is how can the scrutiny be applied and how can we trust the system?
I also suggest looking at some of the chat sites from the US. They are not even getting the medication on their insurance that I already receive in the UK.

Ah death panels.

We cant afford it so you cant have it.

Ah death panels.

We cant afford it so you cant have it.

Oddly enough, the above is a sentiment that right-wing concern trolls are happy to endorse, completely unironically, in every area of government spending that doesn’t involve funnelling billions of pounds directly into pharma companies’ bulging pockets.

@ 12. Yes, there is a reason Avastin is so expensive: it’s under patent.

Patent was granted in 1995, so it should be coming out of patent protection in 2012 (although this does depend upon each individual country’s patent). Then it can be, at least legally it can be, cloned and offered as a generic.

No, I’ve no idea what the actual manufacturing costs are but I’d be amazed if they were more than £1,000 per year of treatment.

The current high cost is because we grant those patents: they may or may not be the best way of encouraging new drug production but we do need to have a method, somehow, someway, to encourage people to sink that $ billion it costs to bring a new drug to market (plus, of course, all the ones that get part developed and then dropped because they don’t work).

@17 Tim Worstall

I understand that the drug is under patent. Having spent a few years in pharmaceutical research I have some grasp of the ins and outs of drug development too. However without more technical information it still seems there’s some profiteering going on.

“still seems there’s some profiteering going on.”

Well of course there is. That’s the whole point of having patents: so that people can make profits.

Oh Tim, now you’re being deliberately dense!

@17

What a ludicrous set of statements.

First, patent was awarded in 2000. It holds patent exclusivity through to 2019. But that’s not enough for them. By constantly pushing for new indications (while actively encouraging “off-label” (unapproved) use, including paying doctors to do so) they extend the period for which Avastin enjoys exclusivity.

Between now and 2019, if it just maintains current sales, it will generate 45 billion USD.

Now let’s assume your statement that it costs a billion dollars to bring a drug to market (it doesn’t – even the legendarily wild-eyed 802 million USD claim by Tufts researchers funded by Big Pharma didn’t go as far as you have there, and any unaffiliated researcher can tell you that at least half that number isn’t capital outlay but rather, hysterically, lost opportunity cost). Is it profiteering to demand obscenely high prices for a drug that generates tens of billions of dollars in profit over its lifecycle (which will be extended by years through combination products, new indications and general lifecycle management techniques, let alone licensed generics, etc.) and then plant stories claiming the NHS is evil and twisted for not paying those high prices?

Yes.

Yes it is.

Profiteering of the worst kind.

And energised by the far right press and their Liberal toadies.

I agree with a great deal of what you say, Imran – but what a pity NuLab served the NHS up to the coalition on a plate?
http://www.redpepper.org.uk/Dismantling-the-NHS

I’ve been a virulent critic of New Labour’s tinkering with market mechanisms within the NHS. Yes, experiments like foundation hospitals (with their hysterically myopic governance mechanisms) were loathsome. But there is no doubt that the NHS was in better hands with a party that doubled real-terms investment, vastly increased the numbers of doctors and nurses and helped make the NHS viable after 18 years of Tory misrule. Mechanisms like NICE run contrary to the hackneyed, trite and ahistoric anti-”NuLab” faction’s propaganda. NICE helped substantially in obviating the postcode lottery issues and took it directly to Big Pharma, replacing maudlin emotion and the filthy lucre of “detailing” with a cutting-edge evidence-based system of deciding on treatment pathways and drug selection.

Overall, I rest entirely confident that despite “NuLab”‘s tinkering, the service is in a far better state today than it was in 1997, that it is once again a viable National Health Service, and that I, and anyone that actually wants an NHS, would far, far, far rather have it in Labour’s hands than those of the market fundamentalists of the Tories and, as fresh revelations today have simply confirmed to me, the utterly sociopathic mendicants of the Liberal Democrat party.

@ 21 “First, patent was awarded in 2000.”

You might be right, don’t know.

A search for “Avastin patent” gts this:

“Avastin is the first biologic to be approved in a new class of drugs know as angiogenesis inhibitors – drugs which work by blocking the growth of blood vessels, thus denying tumors blood, oxygen and other nutrients needed for growth. This approach to fighting cancer has been studied for three decades. It was approved in February 2004, and sells for $4,400 – $8,800.

Patent Number: 6,054,297 – Humanized antibodies and methods for making them
Filed: May 9, 1995
Granted: April 29, 2000
Inventors: Paul J. Carter and Leonard G. Presta
Patentee: Genentech”

Do note that exclusivity date (at least as I understand it, please do correct me if I am wrong) runs from filing date, not grant date.

Then, I think at least, that patents are 17, not 19 years.

“By constantly pushing for new indications (while actively encouraging “off-label” (unapproved) use, including paying doctors to do so) they extend the period for which Avastin enjoys exclusivity.”

No….they enjoy exclusivity for approval for treatment for that new use: they do not, at all, enjoy extend patent life for the drug itself. nd , given that each extention of use costs some hundreds of millions of $ more in tests, why shouldn’t this happen?

“even the legendarily wild-eyed 802 million USD”

OK, fine, how much does it cost then? I understand that the expensive part is the Phase III trials. Want to give us a number here?

“and any unaffiliated researcher can tell you that at least half that number isn’t capital outlay but rather, hysterically, lost opportunity cost”

If you don’t understand opportunity costs then you not, I’m afraid, educated enough to discuss matters economic with the adults.

You’re simply not.

“Is it profiteering to demand obscenely high prices for a drug that generates tens of billions of dollars in profit over its lifecycle ”

Yes. it is profiteering. And good for it too. Because that’s how we encourage other people to do the research, spend the money on the various trials, try to get something approved, which then goes on to cure people. You know, cause that “not death” thing which we all desire.

Now, it may well be that this isn’t the best way to do this encouragement: there are other systems possible.

So you are now going to detail those other systems and show why they are better are you? You know, show uis a better way to produe the new drugs that we all desire?

I’m quite unwilling to do your research for you. Spurious claims seems to be your stock-in-trade. The Internet will suit you well, friend.

Frankly, it’s quite clear that your heart bleeds for those poor pharma companies and that you think their ability to profiteer at the expense of the desperate is a higher right than the right to good health and life.

Good for you. Why on Earth you think we might come to some… dialectical synthesis is beyond me.

“Frankly, it’s quite clear that your heart bleeds for those poor pharma companies and that you think their ability to profiteer at the expense of the desperate is a higher right than the right to good health and life.”

No, not quite.

I’m simply making the observation that if you want to change the current system then you really do need to tell us what you would replace the current system with.

Currently the development of a new drug costs some mindboggling amount. We use private capital to fund this research and production. If we’re going to use provate capital to do this then yes, we do need to rig the system so that private capital can make a profit by doing so.

For the drugs, once discovered and licenced, are, to a large extent, public goods. They’re non-excludable. Anyone with a decent set of lab equipment can (as the generics companies prove) produce the drug once those hundreds of millions/billion whatever have been spent on the knowledge that the drug actually works and is safe.

Now, if you think that’s the wrong model then great, I’m all ears. I too would love to have a system where we did still get new drugs being developed, did still have those multi-billions being spent on keeping us all alive in the future and without that 10-17 year period of eyewatering expense for the new drugs.

But you do need to be telling us what you’d replace this system with, not just decrying it.

So, what is your proposal for lowering the price of drugs while still encouraging anyone, anywhere, to keep spending on finding new ones?

[26] you can’t see anything wrong with Big Pharma – then take a look at this and ask yourself do want more or less of this sort of thing in the NHS?
http://www.thedoctorsvideos.com/video/15609/Cancer-Cure-Myth

@27: I don’t say that I don’t see anything wrong with Big Pharma. I can provide quite a list of what I think wrong with it actually.

What I am trying to ask though is what would people like to replace it with?

@ 15

“Ah death panels.

We cant afford it so you cant have it.”

Ah yes. So much worse than, say, the previous American system of “you just can’t have it.”

Anyone who opposes state healthcare on the basis that it involves so-called death panels is either a lying, hypocritical opportunist or a fucking idiot.

Tim,

Let me tell you my dream of how we can balance private enterprise with the public good and a finite economic system.

Hold on folks, this might blow your mind.

I would like a system where a hard-nosed, dispassionate, empirical organisation takes pharma companies to task when they are overcharging for their drugs. I would like it to use economic measures like cost per some intelligently-calculated unit of benefit given to patient to turn away those chancer companies that try to overcharge the country.

This organisation will work at a national level, so we don’t have a grotesque system where GP consortia decide to compete against others by permitting one drug and then bankrupting themselves early in an accounting period and having to be bailed out by the state so that they can prescribe even the most basic drug.

This judicious and pragmatic system would be pretty darn nice, now wouldn’t it.

Define “overcharging for drugs”.

There are two possibilities that are relevant here.

1) Too much cost per Qualy during the patent period.

2) Too much cost per Qualy after the patent period and the manufacturing by generics producers.

I agree absolutely that the second would be over charging. However, given the drug innovation system we have, we need to be very careful indeed to make sure that by being rigid on 1) we prevent 2) from ever happening at all.

Which is why I’m interested in what you propose to replace the innovation system we have with? We do, I assume, agree that we’d like to get as many new drugs as we possibly can. If we’re not going to pay in period 1), then how, otherwise, are we going to get to that lovely situation in 2), lots of cheap producers of desirable drugs?

Overcharging for drugs is defined as charging a price that does not reflect the benefit conferred upon patients.

In the United Kingdom that is calculated to be £30,000 per quality-adjusted life year, which is a measure of the benefit derived from a drug to a patient.

If any drug – whether an innovative small molecule or a biologic agent, a generic small molecule or a biosimilar (you of course understand the problems with creating generic versions of monoclonal antibodies) – can’t meet these standards, we can objectively state that the drug is overly expensive and reject it for use in our NHS.

Their choice is not the franky baffling binary choice you offer: that either we purchase it and they make money or we don’t and they don’t. They could, for example, drop the price and derive less profit per unit but still increase their profit substantially overall, or not.

That way we can maintain the economic integrity of our NHS.

Roche certainly has some room to manoeuvre. Last year, for example, they made 15 billion CHF in pure profit on sales of less than 50 billion CHF (with less than 10 billion spent that year on R&D) – those are some healthy margins. And all that in a year where they’d raised money to spend 48.2 billion CHF on Genentech (owners of Avastin, the drug in question).

Of course 2) doesn’t exist in any real sense for biologics. The drop off in pricing for biosimilars is not like it is for small molecules. You don’t get the legendary 90+% overnight drop in mean price that we saw in the US (the world’s most advanced generics market) for Viagra upon patent expiry. The approval pathways for biosimilars are complex, nascent and there aren’t a huge amount of successful examples out there. In general, the drop-off in price is 10-20%. What would stimulate price cuts is competition, and I can certainly see why we invest so much into our universities, which are creating NCE angiogenesis-inhibitors that will eventually force Roche, which owns the first such molecule, to lower its price when they’re not in a monopoly situation.

But what seems clear in your advocacy is that you would prefer a system where drug manufacturers can charge anything they want, we pay anything they want, and then cross our fingers and pray that generics come along that save our arses from bankrupting the NHS. That seems… not that conservative really and anyone with an ounce of sense here – you too? – can see how specious your argument has become.

[31] Define “overcharging for drugs” – NICE did just that and earned themselves the soubriquet ‘death panels’ for their efforts [15].

Ahh, if only complex health decisions could be reduced to a simple matter of double entry book keeping.

“Overcharging for drugs is defined as charging a price that does not reflect the benefit conferred upon patients.

In the United Kingdom that is calculated to be £30,000 per quality-adjusted life year, which is a measure of the benefit derived from a drug to a patient.”

Ah, no, that is in fact something very different indeed.

That is the amount where we calculate the benefit of spending taxpayers’ money on a patient. That isn’t, by any means, the same as the benefit the patient might calculate from receiving the drug.

“What would stimulate price cuts is competition”

Absolutely. And we deliberately limit competition by means of patents so as to encourage investment in the first place. Which brings us back to my original point. Given that it does cost hundreds of millions to design and get approved a new drug, how are we to pay for this if we don’t use the artifical limitation upon competition that is the patent system?