NHS England’s setback in the high court over its attempt to get one set of cash-strapped public bodies (local councils) to foot the £10m-£20m a year bill for PrEP treatment rather than another – itself – is the latest manifestation of the health service’s increasing efforts to reduce the number of treatments it pays for, or the number of patients who receive them, or both.
Gradually, and largely unacknowledged, the NHS is rationing access to more and more types of care in order to try to balance its books, even when doing so includes treatments – such as PrEP, with its 90% success rate – that are proven to work but deemed prohibitively expensive in the midst of its decade-long funding squeeze.
Doctors, patients and health charities routinely insist that lives will be lost as a result, but still the process rolls on, affecting different groups of patients every time a decision is made.
Last week, NHS England was criticised by the charity Addaction for “abandoning” people with Hepatitis C, the blood-borne virus that can – if left untreated – cause severe liver problems, by decreeing that just 10,000 patients a year can receive drugs that studies show are effective in 90% of cases.
The 10,000-a-year quota was “manifestly unjust” and would mean “a potential death sentence for thousands”, claimed Simon Antrobus, the charity’s chief executive. About 214,000 in the UK are estimated to be infected with Hep C, and others have it without realising it. Many have contracted it from using needles and syringes to inject illegal drugs.
Addaction is waiting to hear if its application for a judicial review of the NHS’s introduction of quotas last year has been approved, so NHS England may yet have to defend the legality of its decision.
Coincidentally, the BMJ last week published the results of an investigation by academics at Cambridge and Bath universities into the restricted availability of drugs that cost about $ 90,000 per patient in the US and about £35,000 per head in England.
It found that, “NHS England, unable to budget for broad access to these drugs, tried to alter the outcome of the National Institute for Health and Clinical Excellence process [of approving them] and, when it failed, defied Nice’s authority by rationing access to them.”
Dr Andrew Ustianowski, an NHS consultant in infectious diseases who resigned from NHS England’s clinical advisory group in protest at its conduct, told the BMJ: “If you are going to choose a fight, then choosing this battlefield is quite a sensible thing to do – a marginalised population, very high-cost drugs.”
Related: Users of HIV prevention PrEP urge NHS to fund ‘life-changing’ medicine
Similarly, the Anthony Nolan Trust, aided by several dozen doctors, is campaigning to reverse NHS England’s recent decision to stop paying for a second stem cell transplant for people with relapsing blood cancer. Each such treatment gives the recipient a one in three chance of survival but costs between £50,000 and £120,00, which NHS England says is unaffordable. Nolan claims it has handed the 20 people a year who need a transplant but will no longer get one on the NHS “a death sentence”.
Until recently, most rows over NHS rationing have involved decisions by GP-led clinical commissioning groups, the 209 local NHS bodies that hold the health budget in different parts of England, to deny people who need it access to treatment including IVF, cataract surgery, hernia repairs and a new hip or knee.
But NHS England’s need to reduce the cost of what are known as specialised services, which jumped from £13bn in 2013-14 to £14.7bn last year, means it feels obliged to make what the Commons public accounts committee last month called “tough decisions”. It has already been attacked for reducing the number of drug treatments that the newly relaunched Cancer Drugs Fund will pay for from 84 in January 2015 to just 48 now and its budget from £466m to a strictly capped £340m.
NHS England’s actions cast doubt on its chief executive Simon Stevens’s public insistence that the extra £10bn a year ministers have said the NHS will receive by 2020 is enough for it to do its job properly.
With the NHS now desperate to prove it can live within its means, a further tightening of the rationing screw is inevitable, even though the human impact of an NHS struggling to live within its means will be measured in greater suffering, growing unmet medical need, reduced chances of survival, potentially higher costs in the long term, and more early death.
PrEP rationing is symptomatic of NHS bid to cut costs, at all costs
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