Reforming the cancer drug fund.

The Cancer Drug Fund was originally conceived as a temporary measure, until value based pricing for drugs was introduced, to give NHS cancer patients access to drugs not approved byNICE. Spending on these drugs rose from less than the £50m (€63m; $79m) budgeted for the first year in 2010-11 to well over £200m in 2013-14, and the budget for the scheme—now extended for a further two years—will reach £280m by 2016. The recent changes to the fund recognise the impossibility, within any sensible budget limit, of providing all the new cancer drugs that offer possible benefit to patients. More radical changes are needed to the working of the fund, given the failure to introduce value based pricing, so that it deals with the underlying problem of inadequate information on the effectiveness and cost effectiveness of new cancer drugs when used in the NHS. A recent The BMJ briefing identified major problems with the fund. The opportunity costs in terms of the treatments that cannot, as a result, be afforded elsewhere in the NHS are substantial, with consequent decrements to other patients’ health. Its operation undermines the role of the National Institute for Health and Care Excellence (NICE). A rejection from NICE on the grounds that a drug is not cost effective (at the price proposed by the company) means little if the NHS funds it anyway through the Cancer Drug Fund. The fund’s existence means that companies have no incentive to compromise on list price, offer a patient access scheme that would justify a NICE recommendation, or conduct further research. Following its recent consultation the fund has proposed several reforms. It will introduce a rationing process that will use a more limited categorisation of the additional benefit (principally in terms of survival) and the cost (simply that of the drug) to prioritise the drugs on its list so that the fund remains within budget. In other words, it will do a crude reassessment of the cost effectiveness of the drug—something that NICE has already assessed and found unacceptable. This process will continue to undermine NICE, duplicate effort, and distort allocation of NHS resources while failing to support the development of cost effective drugs from which patients could benefit. A better process is needed. We propose that the fund should focus on those cancer drugs that may be cost effective but for which current evidence is insufficient. The process could be as follows: • NICE considers new drugs as at present