Are dementia patients worth £2.50 a day?
WHEN Labour first came to power, Scotland’s newly installed health minister, Sam Galbraith, pledged to end the iniquity of so-called postcode prescribing. It is a sentiment which has been echoed by each of his successors to the post. However, despite record levels of investment in the NHS, rationing remains a daily and often harsh reality, and one which is still far from being satisfactorily resolved.
The problem of balancing the cost of treatment with clinical priorities has been crystallised by the ongoing controversy surrounding the only available drugs for patients with Alzheimer’s disease.
Tomorrow a consultation on draft recommendations by the National Institute for Clinical Excellence (NICE) to withdraw the cholinesterase inhibitors donepezil (Aricept), rivastigmine (Exelon), galantamine (Reminyl) and memantine (Ebixa) from prescription in England and Wales on cost grounds will draw to a close.
NICE accepts that there is good evidence from clinical trials that the drugs are effective, delaying the advance of symptoms, on average, by six to nine months, improving memory and helping patients to continue to perform daily tasks. Nevertheless, it has suggested that the costs to the NHS outweigh the benefits.
This has prompted a furious backlash from campaigners who insist that patients with dementia are surely deserving of £2.50 a day. Dr Richard Barker, director general of the Association of the British Pharmaceutical Industry, has described the decision as "heartless and damaging". The ABPI has a vested interest, but points out that when it costs an average of £550 million to develop a new medicine, such decisions will not aid future drug development.
This being election year, English health minister Stephen Ladyman has weighed in to the debate, urging NICE to consider the "wider social implications" of the drugs, including the impact on families and carers, and not just the cost-benefit analysis,
However, cost is a factor: in Scotland alone there are 62,000 patients affected by dementia. If each of them were to be prescribed a treatment which cost £2.50 a day, it could cost the NHS up to £56,575,000 a year.
According to official figures, the net prescribing costs to the NHS in Scotland have virtually doubled in less than a decade, rising from above £477 million in 1996 to just over £917 million in 2004.
Despite concerns about cost, three of the dementia drugs in question, Aricept, Exelon and Reminyl, were recommended for widespread use by NICE in 2001 and the drugs were subsequently approved for NHS prescription in Scotland.
As NHS Quality Improvement Scotland usually follows the recommendations of NICE - "there is no point in reinventing the wheel", as one source puts it - campaigners are understandably concerned that Scotland will follow England’s lead if the new draft recommendations are adopted.
A spokesman for NHS QIS insists Scotland is not bound to follow any recommendation from NICE: "Scotland makes its own decision on Alzheimer’s care but we do understand the concerns people feel. We will be consulting closely later this year as part of the process of Scotland deciding for itself how best to address these issues."
However, the Scottish Medicine Consortium’s website indicates it would be highly unlikely for its umbrella body, NHS QIS, to come to a different conclusion. "If NICE comes to a different conclusion from SMC about a medicine both have assessed, the NICE decision will normally take precedence since it will usually be informed by more evidence on clinical effectiveness."
Jim Jackson, chief executive of Alzheimer Scotland, says it would be "disastrous" if patients are denied access to dementia drugs. "We know that these treatments are not perfect, but they do help people with early-to-moderate-stage Alzheimer’s. It cannot be right to take away treatments that alleviate the symptoms and improve the quality of life for people.
"The introduction of these treatments has led to diagnostic treatments for people with dementia being improved throughout Scotland and recognition that better services throughout the course of the illness are required. If the NICE recommendations are acted on in Scotland, they could take us back to a time when people with dementia and their families were ignored and left to cope as best they could."
Jackson adds: "It appears that NICE has been told to back down south of the border and that takes away the sense of urgency.
However, until NICE itself changes its draft guidance the battle is not over. We will be encouraging our members to continue letting NHS Quality Improvement Scotland know how wrong they thought the draft NICE guidance was. Then it will be a matter of keeping a close eye on any developments.
"We will also be re-examining the arguments about memantine, the fourth drug caught up in the draft NICE recommendations. They rejected its use and previously it hadn’t been recommended for use either by NICE or the SMC.
It is the only drug treatment licensed for use in the later stages of Alzheimer’s disease and we believe that suitable patients should be offered this treatment."
From (thescotsman.scotsman.com)