David Thomson, Lead Pharmacist, Yorkshire Cancer Network

It is clear that PCTs (Primary Care Trusts) are best placed to audit the demand for unfunded drugs, as they are likely to be reviewing exceptional and individual case requests for drugs that they don’t routinely fund on an ongoing basis. This type of audit should be reasonably straightforward and should provide some useful national data on variability of decision by PCT.
 
In my view, the bigger challenge is that of auditing the outcome of treatments. The guidance is not clear as to whether it is the outcomes of all cancer therapies or specifically those for “unfunded” cancer therapies that should be audited. Particularly for “non-NICE” drugs, commissioning colleagues increasingly want to see data on outcomes for their patients—to see that the benefits seen in trials are seen in practice in their patients. There is a risk that the small number of local patients may skew the results, and therefore the proposal for a national approach is welcome.
 
However, there is a danger that current exceptional case and individual case request mechanisms for unfunded drugs can lead to perverse incentives to use the drug in situations where it may be less effective, i.e. the drug being used in a later stage of disease, or the use in a different population from the trial. This may lead to poorer outcomes than expected. If we assume that “unfunded” means “not approved/reviewed by NICE”, then the other risk is the potential for individual PCT’s to fund the same drug in different subsets of patients deemed more “cost-effective”. Any outcome data would have to be interpreted with this in mind.
 
These recommendations coupled with the National Chemotherapy Advisory Group (NCAG) report and many other developments in chemotherapy services mean we have to solve the issue of data collection. E-prescribing systems will assist in the collection of some of the required data. However, I believe that the data and audit collection required by these developments will need e-prescribing solutions to link with other clinical systems in trusts and networks, to provide some overall context to the data. We must solve this one step at a time and start by playing our part in ensuring that all chemotherapy is prescribed electronically.