We have witnessed a revolution in therapeutics in recent years. With every year we are able to treat more conditions than ever before. However we are also conscious that resources for health and social care face unprecedented pressures as people are able to live longer than previous generations.
NHSScotland spends over £1.67 billion a year on prescription medicines (around 14 per cent of overall healthcare spending), with one in five adults in Scotland being prescribed five or more medicines. So when it comes to accepting new medicines for routine use we need to be confident that those medicines are both clinically and cost effective.
The Scottish Medicines Consortium (SMC) is key to this. We assess the benefits of all new medicines compared to existing treatments and decide whether the cost can be justified.
In 2017 alone, we issued 100 pieces of advice, with 68% of those medicines being accepted for use by NHSScotland. The conditions we consider medicines for vary enormously.
For example, just last month we accepted medicines for paediatric onset short bowel syndrome (an extremely rare condition in which nutrients and fluids are not properly absorbed by the gut) hepatitis C, rheumatoid arthritis and plaque psoriasis.
If we consider the volume and range of advice issued over a 16 year period, we know the impact of our recommendations will have been felt by a large percentage of the population.
The views of patients and their carers are increasingly heard in our decision making: only they will know the reality of living with a condition. We take great care in the committee to understand the impact a new medicine might have on them before drawing a conclusion. Last year, our Public Involvement team actively engaged with 186 patient groups, resulting in 87% of our medicine appraisals including a patient group submission, compared to 65% in 2014. Enabling patient interest groups and the public to contribute to a discussion on the likely impact of a new medicine has enriched our deliberations and consequently the decisions committee members are able to make.
However, the reality is that we can’t say “yes” to all medicines that are presented to us. I can fully understand reaction from patients who are looking for hope in a new medicine becoming available when we do not recommend it for routine use. However the only way to make decisions in a way that is fair and equitable to all patients is to base them on balanced evidence that is presented to us by the company, patient groups and clinicians. And we have to take into account all patients who might need treatment, not just the ones who stand to be treated by the medicine under review. If patients and society benefit in the way that the evidence suggests, we will be spending valuable NHS resources wisely. If decisions are not based on objective assessment of the evidence, we run a very high risk of disappointing patients and the public who believe a medicine will help them. We will also be wasting precious resources.
The benefits to both the public and NHSScotland in operating this way are many. Before SMC was established, 14 individual local Area Drug and Therapeutics Committees (ADTCs) advised their respective NHS boards which products should be accepted for use in their area. The introduction of SMC in 2002 provided a single point of advice, reducing duplication of work and differences in availability of medicines across NHSScotland.
I believe the impact of SMC across Scotland has been enormous – I am confident that, by having one national point of advice for boards to follow, SMC has supported a fairer access to medicines across the country and in addition has saved NHSScotland a large administrative burden.
However, no successful operation can stand still and we continue to evolve, listening closely to patient voices and adapting to deal with a complex new medicines pipeline. Following reviews in 2013 and 2016, we have worked with stakeholders from the pharmaceutical industry, NHS and patient groups to constantly develop and review our processes. After the 2013 review, we were given a clear steer to increase access to medicines specifically for those people at the end of their lives and those for people with rare conditions. Since then, having built greater flexibility into our committee’s decision making process, more medicines that fall into these categories have been approved, with acceptances increasing from 48 per cent between November 2011 and October 2013 to 75 per cent between May 2014 and March 2016.
SMC’s work will continue to evolve as the importance of medicines as part of someone’s well-being will remain important. The work is challenging, but critical to ensuring the best use of new medicines in Scotland for both patients and the NHS.
Dr Alan MacDonald is Chairman of Scottish Medicines Consortium.
As a representative of a patient group and having gone through the process last year with a medication, although it was unsuccessful, the support for us from the SMC team was superb. The committee meeting was quite daunting on the day but was ran efficiently and we were allowed our input. My only negative comment on the process was the vote at the end, the ballot by certain members was carried out at the table but the results are kept quiet until a few weeks later. I would encourage the SMC to take the bold step to make this visible on the day, not to allow a challenge but to have it fully visible as we take our position and opinions to the table it would be good to see the committee give their opinion openly too.