The prescribing of costly medicines is examined by a new working party report from the Royal College of Physicians. It discusses rationing and prioritisation of treatment, evaluation and licensing of drugs, ethical and legal perspectives and setting priorities. A costly medicine is defined as "one that is expensive when the overall cost of its use is compared with the overall cost of using currently recommended treatment".
The report makes 10 recommendations, at the centre of which is strong support for the expansion of the work of the National Institute for Clinical Excellence (NICE). The report says that the NHS should not agree to purchase costly medicines until their clinical and cost effectiveness have been evaluated by NICE. Once a new medicine has fulfilled the criteria to qualify for purchase by the NHS, it should become generally available, to avoid "postcode prescribing". When the NHS has decided not to purchase a medicine, it should be unavailable except by private prescription.
Medical professionals should be involved in the choice of priorities but, once the choice has been made, individual doctors should do the best they can within the constraints imposed. The way in which priorities are set should be made more transparent and the fact that not all medicines are affordable should be openly discussed, says the RCP.
The RCP suggests that local purchasers should set up prescribing committees to review the use of costly medicines.
Looking at setting priorities, the report says that the problems of relative health gain and value for money can be represented by three groups of drugs. The first is drugs with high acquisition cost but very low volume use (eg, human growth hormone). The total cost of treating a small number of people is less than for the other two groups but it is a high cost for an individual patient. Second is drugs with high acquisition cost and modest volume use (eg, interferon beta). The dilemma for interferon beta, the RCP comments, is that there is a slender chance of benefit but all patients with multiple sclerosis would want to know if they fell into the 10-20 per cent who would benefit from treatment.The third group is drugs with low acquisition cost but high volume use (eg, statins). The cost of prescribing statins to the total number of people eligible for primary and secondary prevention of coronary heart disease is unlikely to be affordable to health authorities or primary care groups but ethical considerations of not prescribing have to be considered, too, the report says.
"The prescribing of costly medicines" , £25; Royal College of Physicians publications department (tel 020 7935 1174, ext 358). Also available on the College's website (www.rcplondon.ac.uk/pubs/wp_pcm_home.htm).