by Dr Padraig Dixon
Senior Research Associate
Centre for Academic Primary Care
Imagine being given £400m of taxpayers’ money to spend on drugs for the benefit of NHS cancer patients. How would you decide which therapies to fund? Would you decide that all cancer patients should benefit equally, or would you decide to spend more on particular types of cancer, or on particular types of patient?
These issues were confronted by the Cancer Drugs Fund (CDF), the 2014/15 expenditures of which were £416m (against a budget of £280m). The CDF was created to make available to patients in England cancer drugs not recommended by the National Institute of Health and Care Excellence (NICE) on the basis of cost-effectiveness, not yet appraised by NICE or which were being used outside market authorisations.
The effects of the CDF on population health are controversial: one estimate is that the CDF has caused five times more quality-adjusted life years to be lost elsewhere in the NHS than it created for cancer patients.
In a recent article, we put to one side the issue of whether the CDF ought to exist at all, and considered how the CDF decided which therapies would be funded for the benefit of which patients. The issue is relevant, as it speaks directly to fundamental questions about the ethical basis for priority setting in healthcare. These issues are important for the future of the CDF (reforms will be introduced from 1 July 2016), to other jurisdictions considering the creation of cancer-specific appraisal and reimbursement authorities, and to debates concerning healthcare resource allocation more generally.
For example, the decisions made by the CDF since late 2014 tended heavily to privilege survival above other assessed aspects of care, such as quality of life and therapy toxicity. The CDF distinguished between rare and non-rare cancers. One consequence of these approaches to prioritisation is that not all of the patient beneficiaries of the scheme had an equal chance of treatment and benefit. This approach may be contrasted with that of the NICE, which (with some exceptions) treats equivalent suffering equally, irrespective of the underlying health condition. NICE also attempts to rely on evidence that accounts for trade-offs between aspects of care (such as quantity and quality of life) that matter to patients, whereas many of the emphases of CDF are of unknown relevance to patient health.
The CDF offered little or no justification for its decisions beyond short consultations and some input from cancer clinicians and patients. Final scores awarded to funding applications were not published on the grounds of commercial confidentiality. The body that assessed requests for reviews of CDF decisions stated in response to an appeal that it ‘…did not accept that there is a requirement to explain how the scoring system has been derived or how the incremental scores have been developed and tested’.
It is unknown whether cancer patients, or the general public, supported the CDF’s approach, although there is evidence that the general public does not support the privileging of anti-cancer therapies above other disease areas. The CDF did not begin to collect outcome data until several years after its creation, so even a narrow consequentialist assessment of decision making within the CDF cannot be undertaken.
The CDF was a health system in microcosm – it had a finite budget that it had to allocate between treatments in order to meet some objective connected to the health of the patient beneficiaries of the scheme. The value of looking back at how it spent over £1 billion at a time of severe strain on the rest of the NHS is that it can help inform debates to identify an accepted ethical basis for allocation decisions. If some patients (and their diseases) are more equal than others, it is critical that these debates occur so that the logic of allocation decisions is exposed and their consequences confronted.