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Statement to the House of Commons by Rt Hon Alan Johnson MP, Secretary of State for Health, 4 November 2008, on the Richards report, Improving access to medicines for NHS patients

With permission, Mr Speaker, I would like to make a statement about Professor Mike Richards’s review of current policy concerning NHS patients who wish to pay for additional private drugs.

I would like to begin by paying tribute to Professor Richards and his review team for the diligence with which they have conducted this review. The report is informed by evidence from thousands of patients, carers and clinicians across the country, and was completed with necessary urgency, but without in any way compromising its thoroughness. The timescales I set were deliberately challenging because this is an issue that is causing great concern and distress to a number of patients and their families.

The terms of reference for this review were to examine current policy relating to patients who choose to pay privately for drugs that are recommended by their clinician but not funded by the NHS and who, as a result, are required to pay for the NHS care that they would otherwise have received free of charge. I also asked Professor Richards to make recommendations on whether policy or guidance could be clarified or improved.

Professor Richards quickly identified the underlying causes of the problem. His review starts from the fundamental principle that the NHS provides a universal and comprehensive service to all of its patients, free at the point of need. During the second reading of the 1946 NHS Bill, Nye Bevan described the financial anxiety endured by people seeking medical help as the first evil that the NHS must vanquish.

Yet Professor Richards’s report shows that access to certain treatments on the NHS – particularly drugs for the terminally ill – is inconsistent, and as a result, a very small number of patients feel that they have to pay for additional treatment, and are worried that in doing so, they will jeopardise their entitlement to NHS care.

His report makes recommendations not only to revise the guidance for these exceptional and rare circumstances, but also to improve access to certain drugs on the NHS, reducing the need for such patients to resort to private care. His recommendations are accompanied by proposals put forward by Professor Sir Michael Rawlins, chair of the National Institute for Health and Clinical Excellence (NICE), to employ greater flexibility in the appraisal of certain treatments – specifically those relating to drugs for the terminally ill.

I accept Professor Richards’s recommendations in full, and today, I can announce two immediate developments to make more drugs available on the NHS to those who will benefit from them.

Since it was established in 1999, the National Institute for Health and Clinical Excellence has ensured not only that many thousands of patients benefit from access to the latest treatments, but also that the taxpayer gets value for money.

NICE provides wholly independent and scientifically rigorous assessments of the latest medicines and treatments and is widely admired across the world for its work.  Its guidance on drugs and treatments is internationally respected, and many other countries are adopting similar models.

The price of the drugs that NICE assesses is a matter for the manufacturers. I can also confirm today that I am working closely with the pharmaceutical industry on new and more flexible pricing arrangements that will increase patients' access to new drugs. These arrangements will include enabling drug companies to supply drugs to the NHS at lower initial prices, with the option of higher prices if value is proven at a later date. The new arrangements will also build on patient access schemes already developed for particular drugs. This will help ensure that patients can access medicines that would not otherwise have been deemed cost effective by NICE, I expect to be able to say more about this very soon.

In addition, NICE itself has for some time been concerned about its ability to take into account the premium that society places on helping those with terminal illnesses.

Professor Sir Michael Rawlins has written to me to outline a new, more flexible approach to the appraisal process in order to address these concerns. NICE proposes to introduce more flexibility in the evaluation of higher-cost drugs, which have been shown to extend the lives of terminally ill patients, and where the less common nature of a particular condition may mean that the more flexible pricing arrangements we are already discussing with the industry are not in themselves sufficient. The proposal will be implemented immediately whilst NICE holds a full consultation.

These two measures will ensure that more treatments, which in the past patients may only have been able to access privately, will be available free on the NHS.

The work of NICE is necessarily complex, but as we highlighted in the Cancer Reform Strategy, it sometimes takes too long. Its appraisal guidance has often not been available for two years or more after a drug has been licensed. Steps have already been taken to address this, with, for example, fast-track procedures to automatically appraise significant new cancer drugs.  But the time it takes NICE to publish guidance can lead to significant local variation.

In response to Professor Richards’s report, I am today setting out a new timetable to speed up the appraisal process for all drugs evaluated by NICE.

In 2009, draft or final guidance will be available within 6 months of licensing for about half of the drugs that are being appraised through the fast-track Single Technology Appraisal programme.

In 2010, draft or final guidance for all new cancer drugs will be available on average within six months of a drug being licensed.

We will work with NICE to explore further ways of speeding up the appraisal process with the intention of announcing the outcome of our work early in the New Year.

All of these measures, Mr Speaker, will dramatically reduce the instances where a drug is available on the market, but primary care trusts have no guidance from NICE on which to base their decisions about funding a particular treatment. However we cannot totally eliminate instances where primary care trusts have to make decisions in the absence of NICE guidance altogether.

Professor Richards has found that patients and professionals often aren’t clear who is taking such decisions, or how they are making them. Patients and their families are often left bewildered as to why a particular treatment has been denied, despite what they see as a clear clinical need. As we highlighted in the NHS Constitution, we need to do more to improve the quality and consistency of these decisions, particularly during any interim period before NICE’s guidance is released.

We will therefore publish a set of core principles to inform how primary care trusts make decisions on the funding of new drugs. It is essential that the process as well as the decisions are clear and accessible to patients and the public, so if a patient is denied access to a particular treatment, the reasoning behind that decision is both transparent and consistent. 

We will be publishing detailed good practice guidance for PCTs about the processes they should have in place to make decisions about the funding of new drugs and their handling of exceptional cases.

Mr Speaker, better local decision making, a faster appraisal process, fairer pricing and greater flexibility in the evaluation of certain treatments will address the main issues that have fuelled the demand from some patients for additional private treatment.

But it would be unreasonable to expect the NHS to fund every single new treatment, and we cannot guarantee that we will completely eradicate the circumstances under which a very small minority of patients wish to pay for a drug that the NHS does not provide. The vast majority of people Professor Richards spoke to during his review thought that in these circumstances, it would be wrong to take away a patient’s entitlement to NHS care because they had purchased an additional treatment privately. Professor Richards recommends that this practice should end and I agree with him. It will end with immediate effect.

But he is also clear that there must be tight controls to prevent the NHS becoming a two-tier system.

Today, we will publish draft revised guidance to take immediate effect in order to ensure that the NHS is clear on how to deal with the rare occasions (which, with the implementation of the proposals already mentioned, will be even rarer) where patients opt to fund additional drugs privately. The guidance will make clear that in those circumstances:

• NHS care should never be withdrawn; and
• administering private care should take place separately from NHS care to ensure that NHS funds are never used to subsidise private care.

In short, Mr Speaker, there is no question of patients who are able to pay more being able to access a different and higher level of NHS treatment. But neither should any patient who has at some point paid for private treatment lose their entitlement to NHS care.

Today’s draft guidance sets out that in such circumstances, private treatment should be provided in a private facility, so that it is always clear whether a particular treatment is NHS or private. This removes any confusion over what constitutes a single visit or a single episode of care. It will also remove any question of there being a two-tier system, where those who pay for additional care are having their private care subsidised by the NHS.

Mr Speaker, the NHS must by definition be continually evolving and improving to meet rising expectations and to offer the latest advances in medical care to all our citizens, irrespective of wealth, class, ethnicity or disability.

This has been a debate of critical importance to the NHS and the values that underpin it.

I believe the measures I have outlined today, in enabling the NHS to exercise its natural compassion, will actually help to secure these values for the future. We are fortunate in Britain to have a health system that provides a comprehensive service for all patients; based on clinical need with public funds for healthcare devoted solely to the benefit of the people it serves.

The report by Professor Richards enhances these principles, and I commend this statement to the House.