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Phil Ayres: Question of access for patients and new treatments
AS a medical manager, the issue of access to new technologies – including new medicines – is one of the toughest we deal with.
We all recognise that pharmaceutical companies are not charities – they must make a profit for their shareholders. Practical difficulties therefore arise for the companies that are trying to make their products widely available in a highly regulated public service – the National Health Service.
I am no expert in this area, but I do know that the drug companies have a large array of tactics to get their products in use. If they have a new product that works, and they believe will make money as well improve health, why wouldn't they try as hard as possible to make it available?
The NHS needs to respond, and it is therefore right that the Government issues standards and guidance for the use of these new technologies. There is no doubt that what the Government does in this area, through the National Institute for Health and Clinical Excellence (NICE), for example, has improved massively over the last 10 years. NICE is an independent organisation responsible for providing national guidance.
Difficulties still arise when medicines have not yet received a licence to be marketed (and therefore cannot be reviewed by NICE), but doctors and patients want to have access to them. This is because scientific evidence may suggest that the new medicine works, but no guidance is available about whether – and how – the new medicine should be used.
It is possible for patients to get stuck in grey areas like this. What they and the hospitals need is swift access to information about which patients might benefit from specific new medicines. Such guidance also makes it easier for the hospital to discharge its duty to spend public money wisely, and balance the needs of one group of patients with the needs of others.
There is a key role here for the agencies that control NHS resources. These are the primary care trusts (PCTs), and locally the Strategic Health Authority (SHA) for Yorkshire and the Humber.
Hospitals are not allowed to provide services or medicines unless these funding bodies have commissioned them to do so. Our local PCT in Leeds and the SHA work hard to make things as fair as possible for all patients.
The principal issue is often the timing of the availability of guidance about a new medicine. I agree with charity fundraiser Jane Tomlinson's family that the time between knowing a medicine is effective and making guidance available for doctors and patients should be as short as possible. For this reason, I was more than prepared to work with the family to try and increase our understanding about what will speed things up.
Of course, it is in the doctor's consulting room that these matters are brought into sharpest focus. The doctor's first responsibility is to the individual patient but we also need to take account of the implications of our actions on others. Treating one patient with an expensive new medicine may mean that we cannot provide something for someone else. This is not always about money – it may be that we just cannot be in two places at the same time. Such choices become very difficult if the benefits of new drugs are marginal or unclear, and in the absence of guidance, it is almost impossible to say "No" to the patient sitting in front of you if you believe that you can help them access something that will work.
Guidance can come from the Government, through the PCT or SHA, or it can come from the doctor's local hospital trust. In the latter case, it is always better to have doctors and managers working together to develop guidance and this happens routinely in Leeds. I am familiar with the processes that are used in Leeds Teaching Hospitals to generate such guidance.
As a citizen of the city, and a patient of the trust, I am confident that those processes are robust and professionally executed. What would make it easier is fast national guidance for all NHS bodies to use: the system needs to be more responsive.
These situations are not going to stop happening – drug companies will always be producing new medicines; doctors and their patients will want to use them if (and sometimes this is a big "if") they are certain the benefits outweigh the risks. But resources are limited and at some point, when the benefits are small or come at an enormous price, someone has to say "No". Deciding when to say "No" is an unenviable task, but unless it happens, others, who could benefit from cheaper or more effective treatments, would lose out and that can never be acceptable.
What Mike Tomlinson is asking for is for a quicker process to review the effectiveness of new medicines. He also wants guidance to be available about who, in the NHS, should use them, and up-to-date information about where they are available. This will not make everything available, but it would make sure that people have an equal chance of getting effective medicines if it is agreed they should be made available.
Phil Ayres is deputy medical director of Leeds Teaching Hospitals NHS Trust. The opinions expressed in this article are the personal views of Dr Ayres, and do not represent formal trust policy.
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Saturday 26 May 2012
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