Medicines man with eye on patient care

THE FRIDAY INTERVIEW

AS THE "gatekeeper" to Scotland's medicines cabinet, Professor David Webb faces a difficult balancing act between the wishes of patients and a tight NHS budget.

The chairman of the Scottish Medicines Consortium (SMC) is often at the sharp end when his organisation has to say a drug is not cost-effective for the health service.

Such decisions are always difficult, but Prof Webb believes pharmaceutical companies are not helping themselves or Scottish patients by pricing drugs too high for the benefits they provide.

And he urges manufacturers to be realistic about their price tags if they want their products to be used in the NHS.

It is a problem which can only grow as more and more complex and expensive treatments come on to the market in the next few years, but the NHS budget fails to increase as the same rate.

Despite frequent criticism of its decisions, Prof Webb is positive about the work the SMC does.

Its fast-track system does mean that patients in Scotland generally have access to many treatments months in advance of people in England – a cause of much consternation south of the Border.

However, sports enthusiast Prof Webb believes the answers to Scotland's health woes do not lie purely in the world of medication.

It is clear that if Scotland is to rid itself of its "sick man of Europe" tag, we are going to have to look at options other than the pharmacy.

Q & A: PROFESSOR DAVID WEBB

What is the Scottish Medicines Consortium (SMC)?

A group of clinicians drawn from all of the health boards in Scotland who come together to look at all new medicines and make a decision for Scotland about whether they provide good value for money. So it is NHS staff working for the NHS for the benefit of patients.

Why does Scotland need the SMC?

I think, along with the Health Select Committee in London and the Office of Fair Trading, that everyone needs a rapid appraisal process for new drugs. We just happen to be world-leading in Scotland.

It is a great system. It allows patients early access to innovative medicines, and I hope it will be adopted south of the Border.

The SMC's nearest equivalent in England is the National Institute for Health and Clinical Excellence (Nice). What are the differences between Scotland and England when it comes to assessing new drugs?

It will never take less than a year at Nice to assess new drugs because of the structure of their programme, which involves a period of analysis and several rounds of consultation. We can do it within two months of the drug becoming available. On average, we do 90 per cent within four months. On average, Nice comes in 12 to 14 months later than us. That is a long time in which Scottish patients have access to drugs that might not be made available in England.

Is it fair Scottish patients get access to drugs quicker than in England?

It is a really good system for Scottish patients, and we hope that it will become available elsewhere. At the moment, there is no reason why NHS trusts in England and Wales can't look at our advice. We know lots of them do, so they can adopt the Scottish view at an earlier stage while they await a Nice decision. The drugs are launched the same time in England and Wales and Scotland; it's just that our advice comes sooner.

People often worry about postcode prescribing in the NHS. Does this still happen in Scotland, and will we ever get rid of it?

There are some people who describe some things as postcode prescribing which are not postcode prescribing. You could have one particular ACE inhibitor (a drug to treat high blood pressure] available in Glasgow or Edinburgh and the SMC then approves a new one. If there is already one available, it is not necessary for you to take on the new one.

It is really about whether there is already an appropriate treatment already available for patients which can do the same job. Some people misleadingly suggest that is postcode prescribing, but it's having a medicine that is available that is important.

In terms of real postcode prescribing, what was a worry before was individual NHS boards were doing the work and coming to different conclusions. Now the SMC does that job rapidly and consistently for the whole of Scotland. Clearly, if they don't have another equivalent available we would hope they would make those drugs available, and so would the Scottish Government. That is a matter between the boards and the Scottish Government, not for SMC. We provide the advice and it is up to boards to adopt it.

Is it frustrating if health boards are not taking up the advice?

I would hope they take up the advice as soon as is practicable. There may be different challenges to particular health boards in terms of funding and resources to support new services. Some may find things easier than others, but we would like to see our advice brought forward, as that is to the advantage of patients.

Is SMC better than Nice, and what could they learn from us?

I think Nice is an incredibly valuable organisation. In terms of new medicines, what they really do well is in-depth appraisals at a relatively late stage on selected groups of high-profile medicines. We find that helpful, because it's always nice to have a review of our decisions. But I think in terms of the needs of health boards and the needs of patients, it's really important to have an early appraisal system. I think that is what Scotland provides really effectively.

The early approach taken by the SMC and the later approach taken by Nice are very complementary.

What has been said is that the approach by SMC is "rough and ready" or "quick and dirty". I would not accept either of those. I think it is a really robust process with the evidence that we have available.

The evidence we have in support of that is that, for the 50 or so drugs Nice has looked at after SMC, a year or so later, in all but a handful we came to the same conclusion. Where we disagreed it is a matter of splitting hairs.

When the SMC rejects a drug, it can cause a lot of anger and frustration among patients. Can you understand that and how would you justify those decisions to patients?

I certainly understand their frustration and fully sympathise with how they might feel if they are not getting access to a new medicine. At the same time, we are trying to make the best use of NHS money.

If we use a medicine that is not cost-effective, that is costing much more than the benefit it provides, given that there is a limited NHS pot to pay for all our services, that means somebody who could have a better-value treatment is not receiving it.

I understand patients' position, but in a sense the reason we say no is generally because a drug does not offer much in the way of advantage, and in other (cases] the price has been set too high by the company for the benefit provided.

If you had a family member who needed a drug not recommended by the SMC, how would you feel and would you pay for it privately, as some patients choose to do?

That is a very difficult question, because I have never been put in that situation, so I don't know how I would respond. But my family and I, and my extended family, have always used the NHS and found it to be a really excellent service.

I think I would go with NHS treatment, and it's important to recognise that, where we have said no, it's probably because the medicine is not one of the best options around.

But there are some drugs which doctors believe would benefit patients, such as the cancer drug Avastin. Have you ever regretted a decision made on a drug?

I am very pleased with some of the decisions we have made where the evidence was sometimes a bit difficult to be confident about. I am thinking of a drug like Imatinib, for chronic myeloid leukaemia, where we gave some latitude because of the potential benefits it had and we did not know how sustained they would be and that drug has produced really fantastic benefits.

And I am pleased, I think, with all the decisions we have made overall. Avastin was undoubtedly set at too high a price for the benefits it provides, and I believe the company recognise that. The way around that is to reduce the cost of the drug, or through finding a risk-sharing scheme (where the drugs company shares the costs when drugs do not work] of some sort that can allow the price to be brought down.

Is the problem of more expensive drugs becoming available and the NHS being unable to afford them going to become even more serious in the future?

It is very difficult to know. It is all dependent on the pricing of new medicines. I think it is reasonable to price a really innovative and life-saving medicine at a high cost. I think it is more difficult for drugs that make a minor difference.

Do drugs companies need to be more realistic about their pricing?

They are in a very difficult environment. It does seem that some of the "low-hanging fruit" (has] already been covered – drugs for high blood pressure, heart failure, diabetes.

It is more difficult to find those new medicines that will really make a difference. And, of course, shareholders want their profit because there has, in recent years, been a much greater emphasis on ensuring that drugs are safe to use and don't cause unnecessary risk to patients, so the cost of doing studies is very expensive.

It is quite a difficult environment and there have been a number of ideas put forward about better working between the NHS and industry to keep the cost down and benefit patients. That needs exploring.

What advice would you give to a drugs company in order for their drug to be accepted by the SMC?

They should make sure it is a drug with a substantial effect in an area of unmet need, supported by good clinical trials, preferably performed in patients relevant to the Scottish population. It should also be set at a price that is reasonable for the benefit (it] provides.

What did you do before becoming head of the SMC?

I was born in Greenwich, London, and brought up in London and I trained in medicine there.

I moved to Glasgow soon after qualifying to start research training. I returned to London for a few years and then came up to Edinburgh in 1990. I took up a consultant post at Edinburgh University's clinical research centre and I took up my chair in clinical pharmacology in 1995. I started work to help create the SMC in 1997 and became the first chair of the new drugs committee in 2001. I became chairman of the SMC in 2004.

You have three sons (aged eight, 12 and 15]. Are they showing any signs of wanting to follow you into medicine?

I am not allowed to say that. If I say that one might be, it might put him off.

They are all interested in science and they do ask questions about what I do in medicine.

What do you like doing outside of work?

I mostly rock-climb and ski-tour. I have got my children interested in those outdoor pursuits. I like going biking. I also like opera and I used to like playing bridge but I don't have any time for it any more.

Do you think that having a senior role in the NHS means that you have to be a role model to the general public in terms of keeping healthy?

That is the case more and more. You should lead by example, so it is really important that in the UK there are very few doctors who smoke.

More and more doctors are using bicycles and taking exercise, and it is important to make a good example.

Some doctors probably drink too much. That's a Scottish problem in general.

Scotland has long been seen as the "sick man of Europe". Is there anything more we could be doing to get rid of that image?

Clearly, we have an historically bad record, but we have taken a reasonable lead in terms of banning smoking in public places. That has been very good. There are other initiatives in Scotland that are helpful. In the future, the biggest risk is the obesity epidemic where, unfortunately, Scotland does seem to be taking a bit of a lead.

Programmes of exercise (and] fitness are really going to be important to prevent Scotland keeping its leading place as an unhealthy environment.

Medicines are only part of the solution for the obesity epidemic. We need to be taking public-health approaches. We have now got the smoking ban. It will take something a little more subtle for the obesity epidemic, so it needs important work done soon.