BMJ  2006;333:1219 (9 December), doi:10.1136/bmj.39052.480231.FA

Letters

How much will Herceptin really cost?

The money is already there

Barrett et al state that "the real cost of Herceptin is in the other patients not treated, whether they are patients with cancer or those with other conditions"—the opportunity cost.¹ The competing demands that medical professionals across multiple disciplines place on limited resources and their responsibility to ensure the judicious use of publicly funded resources should also have been acknowledged.

It is too easy to blame the National Institute for Health and Clinical Excellence (NICE) when healthcare professionals can enable judicious use of what has already been provided. Moon and Bogle highlighted savings of £1.1 billion (1.6bn; $2.1bn)over five years by promoting the generic substitution of statins for the primary and secondary prevention of cardiovascular disease,² and Barrett et al's strategic health authority estimates savings of £20m this way.³

Clinicians currently have little incentive to seek prescribing savings, particularly if savings are then used to stem deficits. Devolving prescribing costs into locally held unified budgets for clinical service delivery across multiple diseases would promote negotiation and priority setting. Oncologists, cardiologists, and general practitioners would have to talk to each other and ensure the sensible use of public funds.

Introducing a system of reference pricing in which drug reimbursement is pegged to the price of a therapeutically equivalent generic drug could do much to resolve these types of issues at source. Clinicians could decide whether to pay a premium for a non-generic drug from regional budgets or fund new technologies such as Herceptin.

External pressures that should not determine who is treated and what they are treated with can affect prescribing decisions. Specialist professional groups that adopt a narrow viewpoint can be such a pressure. Their guidelines are usually uncosted and promote recommendations that do not consider the impact across other specialties. Uncosted recommendations may be expensive to implement in both mortality and financial terms.

Disinvestment will promote efficient allocation, but as clinicians we must also disinvest ourselves of a myopic clinical mindset that results in "silo medicine." Expecting NICE to provide all the answers is to be blind to our own faults and only shifts the blame.

¹ Sunlight Medical Centre, Gillingham, Kent ME7 1LX anything@rubin.icom43.net

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Competing interests: Over the past 12 months RM has attended advisory boards for Novartis and Pfizer. Over the past 10 years RM has attended educational meetings, received travel grants, honorariums for lectures and advisory boards from a number of pharmaceutical companies, including AstraZeneca, Bayer, Fournier, GlaxoSmithKline, Pfizer, Merck, MSD, and Sanofi-Aventis. RM is a member of the Primary Care Cardiovascular Society and the South Asian Health Foundation. RM is an appraisal committee member in NICE and a participant in NICE guideline development groups.

References

1. Barrett A, Roques T, Small M, Smith RD. How much will Herceptin really cost? BMJ 2006;333:1118-20. (25 November.)[Free Full Text]
2. Moon JC, Bogle RG. Switching statins. BMJ 2006;332:1344-5. (10 June.)[Free Full Text]
3. Gill K. Statins—the SHA perspective. Achieving clinical efficiency. A practical case study. www.heart.nhs.uk/scripts/default.asp?site_id=23&id=28050 (accessed 24 Nov 2006).

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How much will Herceptin really cost?

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