Intended for healthcare professionals


Commentary: NHS patients should have a choice of drug for wet age-related macular degeneration, despite pressure from pharma

BMJ 2017; 359 doi: (Published 01 November 2017) Cite this as: BMJ 2017;359:j5013
  1. David Hambleton, chief officer
  1. South Tyneside Clinical Commissioning Group, Jarrow, UK
  1. d.hambleton{at}

Commissioners have to pay more than lip service to the obligation on us to find cost effective treatment options. Our 12 clinical commissioning groups (CCGs) have therefore agreed a policy to offer the thousands of patients in our region diagnosed with wet age-related macular degeneration (AMD) every year the choice of bevacizumab as preferred treatment.

That bevacizumab is as clinically effective and safe as aflibercept and ranibizumab—which patients will continue to be offered as alternatives—has been shown comprehensively.1 We intend to share information with patients through accessible media (including leaflets and audiovisual material) about the treatment options available, the evidence base, and the comparative costs—and allow them to make their own choice.

The policy could save the region’s NHS up to £13.5m (€15m; $18m) a year over the next five years. That could pay for an extra 270 nurses or 266 heart transplants every year. In a financially stretched NHS, the alternative for CCGs is that we may have to make less evidence based savings, including rationing other treatments such as in vitro fertilisation.

Every patient who chooses the cheaper alternative drug will help the NHS to fund important medical treatment in other areas. We want to have informed conversations with our patients so that they understand the wider effects of the choices we collectively make. If a patient chooses to be treated with aflibercept or ranibizumab then that is the drug that the NHS will provide.

As CCGs, we have no interest in protracted legal disputes, but drug companies should not dictate which treatments are available to NHS patients. The choice between three clinically effective drugs should be one for NHS clinicians and patients to make together.

We are confident that EU drug marketing laws do not allow drug companies to restrict the ability of the NHS to offer patients a choice. Our legal position is strongly supported by an official adviser to the European Court of Justice handed down in September.1 That is why we have responded robustly to Bayer and Novartis, which have threatened a judicial review in an attempt to deny NHS patients this choice.2

The companies frequently refer to “unlicensed” use of bevacizumab, which seems to imply that it is unsafe. This is clearly not the case, either in law or in practice, where licensed drugs are safely and effectively used off-label on a daily basis in the NHS.

We understand that there may be some confusion among clinicians about this issue, and we will offer every support to ensure they can have confidence in their clinical right to prescribe what is best for the patient, while being mindful of their duty to consider the best use of NHS resources.3 The CCGs have taken expert legal advice and we are confident that we are acting lawfully—in the same way that clinicians prescribing bevacizumab to private patients with wet age-related macular degeneration are acting lawfully.

Clinical safety and effectiveness are paramount but, as the legal guardians of finite NHS resources, we commissioners also have a duty to act efficiently, effectively, and economically. Difficult choices are having to be made about the NHS to ensure safety and sustainability— this is one choice that is morally, ethically palatable.


  • Competing interests: I have read and understood BMJ policy on declaration of interests and declare I am lead of the North East and North Cumbria CCG Forum.

  • Provenance and peer review: Commissioned; not externally peer reviewed.


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