As a headline, this seems like a harsh statement to make. As an observation of the organisation and effectiveness of England’s healthcare model, perhaps less so.
What could I possibly be talking about? As many in the Diabetes community will be aware of, in the past four years we’ve seen Fiasp, the Libre, Lyumjev and Libre2 come to market. And yet, access to these life changing technologies is variable and in some cases non-existent.
Let’s start with Fiasp. This is a fast acting insulin. It costs the same as its predecessor, Novorapid. It acts more quickly, so should achieve better post-prandial results than standard Novorapid. And yet, in some parts of the country, you can’t get it. And in other parts of the country, you can only have it if you’re pregnant. Whilst in other areas, it doesn’t matter whether you’re pregnant, male or 12, it’s available. Let’s remember that this is the same insulin that’s now been readily available for around 4 years. One that I first used in March 2017, and it’s still not available in some formularies across the UK. Don’t believe me?
This is the extract for South East London:
Fiasp. Only to be used where first line fast acting isn’t “good enough”. Rather than “worth prescribing if you have patients who give shots with meals (like most)”.
Compared to Derbyshire:
Who have Fiasp listed as an option for adults. And not only Fiasp, but also Lyumjev. And in neither case is the insulin restricted.
FInally, let’s take a look at the North West London formulary:
Fiasp is restricted. It’s not clear what restricted means, but from speaking to people in the know, it basically means that it’s really hard to get it on prescription.
Let’s take a step back for a moment and consider this set of evidence. We have three difference Area Prescribing Committees applying different rules to the same insulin that costs the same price as its predecessor and in many people produces better outcomes. Why does each committee feel they have to apply different rules to making it available in their area? And let’s not even consider that Lyumjev entry in the Derbyshire formulary, which demonstrates they are willing to add a new insulin that potentially provides further improvements within six months of it becoming available, while the London groups haven’t touched it yet.
This highlights yet again what we saw in the roll out of Libre across the UK. Each CCG chooses to do whatever it feels like when it comes to making medicines available, in spite of the fact that in doing so they are potentially acting in a way that reduces the availability of more effective medications that cost no more money. And once again, we can highlight that the “London Procurement Partnership” and “London Diabetes Clinical Network” are neither effective, nor have any point. They simply exist as jobs for NHS administrators that have no impact and add cost. Otherwise these examples of variation simply wouldn’t be happening.
And what of the Libre2?
Well the statement recently was that it should be uniformly available from January 2021. Something that seems fair enough and absolutely should be the case:
And yet the grapevine rolls into operation and we hear that SELondon has postponed its January approval processes for all medications for a few weeks, due to the pandemic, and is therefore unlikely to meet the January 2021 date, while Derbyshire have said that they’re not expecting it to be available until the end of February. Let’s be clear that unlike North West London, SE London is generally very receptive to new T1 treatments, but times are currently tough.
So much for national availability and coordination.
And in the meantime, we roll out a COVID vaccine nationally to all those who need it, without touching a CCG or APC. Which just goes to show that this farce we call local commissioning is an irrelevance when an efficient outcome is required.
So while we are left to live with a massively distributed, bureaucratically overweight system designed to make it difficult to access effective new drugs and treatments, the reality is that it isn’t necessary nor desirable, especially when there’s a pandemic going on.
Can you imagine the outcry if access to a COVID vaccine had been left to the CCG level for approval, and in some areas, it was restricted to only pregnant women?
Perhaps it’s time for the NHS in England to take back control so that we can make drugs and treatments available anywhere in England once they are considered clinically safe, rather than the postcode lottery that’s available right now.
Approved once, available everywhere. That would be the sensible approach.