NICE-Approved Products: Patient Access

Debate between Baroness Winterton of Doncaster and Anne Marie Morris

Tuesday 30th November 2021 Commons Chamber

[Anne Marie Morris]

I could not agree more. It is crucial to realise we are talking not just about medicines and drugs but also devices and, as the hon. Gentleman says, the processes, which are often the connection between the medicine, the device and the patient.

Within these health bodies, there is no training and nobody specifically focused on monitoring innovation, and there is no obligation to prescribe. Even more peculiarly, for these drugs there is an agreement between the industry and the NHS, the voluntary payment scheme or VPAS, under which manufacturers that are members of the scheme effectively agree with Government when the medicine or device is approved that it will be supplied at a well-discounted price. In addition, there is an agreement that sets a cap so that if, as it happens, more prescriptions are written for that particular drug, it is agreed that the extra cost that the NHS has incurred will be reimbursed by the manufacturer.

So if there is excessive prescribing—we assume that is why there is an attempt to limit how much goes on to formularies—why is that a problem when we have the VPAS scheme? It is a problem because the scheme does not the pass the benefit, other than the reduced price, down to the local health authority. The money is put into a separate pot, and that pot is then used generally to support the NHS writ broadly; it is not ringfenced, either for medicines or to be used, as it could be, to support local health authorities—integrated care systems—when their budgets are put under pressure, which is why they do not want too many things on their formularies. This would help them pay the price.

It seems to me, Minister, that there are some solutions here. You will be aware that I raised three of them in proceedings on the Health and Care Bill. To deal with the imperfections of the current arrangements, if those drugs that were approved by NICE—we are talking about the most cost-effective drugs—were mandated to be on formularies within 28 days automatically, so no one had to decide whether they went on or not, that would be a good system. It would also ensure that the decision was in the hands of the clinician and not of the bureaucracy of the health authority.

It seems to me, Minister, that the second suggestion I made—

[Madam Deputy Speaker (Dame Rosie Winterton)]

Order. It is quite important not to address the Minister directly; he should be addressed through me.

[Anne Marie Morris]

Thank you for the correction, Madam Deputy Speaker.

My second proposal is that there should be an innovation officer specifically appointed to look at and manage these issues. Failing all else, there should be a final provision that specifically puts an obligation on the health authority to provide any NICE-approved medicine. Then, as a matter of practicality that is not a matter for the Health and Care Bill, there should be a new arrangement under which the NHS would agree that this pot, rather than going into the general NHS coffers, is put aside specifically to reimburse local authorities.

What about the second category—those drugs that are approved by NICE but not used for the most cost-effective indication? That is called off-label prescribing. We know that a drug in that category does what it says on the tin and we know that it is cost-effective, but it is not sufficiently cost-effective to have got a tick in the box from NICE. Access then is a matter for negotiation between the integrated care system, the NHS and the manufacturer. Often, the starting point will be the list price, but bear in mind that that list price is a lot more than the NHS is paying. The result is that in different health authorities and different hospitals, different patients are offered different costs to be able to access the drug.

There is a real problem on top of all this. To ensure that there is no gaming of the system between access to private healthcare and state healthcare, someone cannot mix the two—quite rightly, we do not want gaming of the system so that people can effectively jump waiting lists—so there is an agreement to enable people to do a bit privately and then jump straight back into the NHS. If there is an episode where someone takes a drug and pays for it privately, technically they cannot then have the ongoing monitoring of their cancer—screening and so on—on the NHS. Individual health authorities recognise that that is rather absurd when we are talking not about a private patient with health insurance but about someone for whom the only way to get the drug is to pay for it, but that recognition is not universal.

So what is the solution for this one?

We need to look at NICE, supported by NHS England, accepting multi-indication approvals. That means a drug company can take a drug and apply, at the same time, for the drug to be approved for different health issues that have different ranges of health benefit. Clearly, the NHS will say, “Hold on a minute. I am not going to pay the same price for something which delivers less health benefit.” That means we need a system of differential pricing, so that a different amount is paid by the NHS for the drug, depending on the use to which it is to be put. That is entirely possible. It is done all over the world.

The Office of Health Economics put out a report, an international study, just this month on “Payment Models for Multi-Indication Therapies”. It concluded:

“Inflexible uniform pricing does not optimally support innovation and access. The most important consequence is lost treatment opportunities for patients.”

I respectfully suggest that the NHS and the Department of Health and Social Care might sensibly look at that. I also suggest, given the clear importance of payment support through industry, that as we move to the next iteration and renegotiation of VPAS, the agreement under which the industry agrees reduced pricing for mass purchase above a certain cap, it will reimburse the Government. That renegotiation needs to include provision for the multi-indication approvals process and differential pricing. 2023 is not very far away and I urge the NHS and the Government to take it forward very quickly. Meanwhile, there should be agreed standard pricing which is effectively paid for and underwritten by the pot set aside as a result of the cap.

There is one final area that needs to be addressed: drugs approved by NICE through a managed access agreement. For some treatments—typically gene therapy, where you are taking body fluids out, effectively changing the genetic make-up, and then putting them back in again—a hub needs to be set up in a hospital. Often, when drugs are approved, exactly how they are going to be delivered is not approved at the same time. Those drugs and processes need to be agreed not just in principle, but together with a package that ensures they can be implemented. As things stand, it can often take three years and much argument before hubs are established and the funding can then flow.

In summary, I ask for a number of things. First, my three new clauses to the Health and Care Bill would require local health system formularies to include NICE-approved drugs within 28 days. Secondly, there ought to be included in the Bill an absolute obligation to provide NICE drugs. It would then be for the individual health authority to work out how to provide them, but there should be an underpinning payment mechanism provided by the NHS. Thirdly—again, I have tabled a new clause on this—we need an innovation officer to ensure the system runs smoothly and that the things that would give best benefit are put on those formularies.

Fourthly—forgive me, Madam Deputy Speaker, there are eight of these—I would like the Government to look very closely at a multi-indication approval system, fifthly, at a differential pricing system and, sixthly, at an appropriate VPAS agreement for 2023. My last asks are about how the money is used. Seventhly, the pot of money, an accumulation of money paid by industry because more of the drug was prescribed, should be made available to local health systems, the integrated care systems, to cover the costs that are not in their mainstream budget. Finally, we should put in place a formal delivery mechanism for every managed access treatment to ensure that it is not just a promise, but actuality. I wonder whether it might therefore be appropriate for this Minister, the life sciences Minister—the Under-Secretary of State for Business, Energy and Industrial Strategy, my hon. Friend the Member for Mid Norfolk (George Freeman)—and the innovation Minister, Lord Kamall, to meet me, because all three have a critical role, given their involvement in access, industry and licensing. I wonder whether it might be possible to persuade them to accept my three amendments to the Health and Care Bill.

It might also be helpful if these matters were raised with the National Audit Office, which could review the current system and look at whether it offers value for money. That would be a very good use of their time. I am sure that the doughty hon. Member for Hackney South and Shoreditch (Dame Meg Hillier), who chairs the Public Accounts Committee, might also be interested in looking at this issue. After all, value for money is critical.

In conclusion, we have a world-beating system but, as it currently stands, it does not provide value for money for all. It does not serve the best interests of all patients, and it does not serve the best interests of delivering the UK life sciences strategy. Indeed, I have one constituent who moved house from Devon to Southampton so that he could get a medical treatment.