Malcolm reflects on ways to improve the treatment of cancer for patients in Scotland
Debate on cancer treatment in Scotland Malcolm Chisholm (Edinburgh North and Leith) (Lab):
I pay tribute to Michael Gray and Tina McGeever for the general contribution that they have made to Scottish life and for their particular contribution on this issue.

In considering the topic, we should set ourselves two complementary objectives. First, we need to maximise the number of effective cancer drugs for patients and secondly, we need to achieve that equitably throughout Scotland. The difficulty with co-payments is that they help the first objective but undermine the second, which is why we face a dilemma.


I will return to that point later, but I will start with the issue of getting effective cancer drugs. I will briefly put in a plug for the Beatson translational research centre, which will put Scotland at the forefront of translational research. A fundraising appeal for the centre has been launched, to which I hope the Government will be able to chip in.

With regard to improving the number of available effective cancer drugs, we need to take two actions in the immediate future. First, it is necessary, as members have said, to review the QALY process—people will know that, in this context, it means quality-adjusted life years—to reflect rising health costs. That would mean maintaining the cost-benefit approach, but allowing a higher cost for a given level of benefit.

Secondly, we need to examine the issue of risk sharing and value-based pricing agreements with pharmaceutical companies. That started in Scotland in relation to beta interferon and other drugs for multiple sclerosis in 2002, whereby if the drugs were not fully effective, the costs that the industry charged to the NHS would be reduced.

In relation to cancer, I have come across one specific example: a response rebate scheme for the drug Velcade, which is used to treat patients with multiple myeloma. Under that arrangement, patients who are making progress have the treatment fully funded by the NHS, but for patients who show no or minimal responses, the drug costs are refunded by the manufacturer. That model should be explored further as a way of getting better value for money.

Great strides have been made on equity in Scotland over the past 10 years, as Dr Andrew Walker acknowledged in his evidence to the Public Petitions Committee. I was pleased that Professor Johnson of Cancer Research UK praised the Scottish Medicines Consortium, saying that it

"is the envy of clinicians who work in England" and that it is "a model of good practice".—[Official Report, Public Petitions Committee, 29 April 2008; c 709.]

When the SMC was set up, there was a debate about the relative balance between centralised and localised decision making. I am sure that we support local decision making in many other areas, but in relation to this matter there must be some central direction. That is why guidance was issued that stated that NHS boards should ensure that recommended medicines are

"available to meet clinical need."


Improvements are needed in that area in relation to monitoring what boards are doing and intervening when necessary. That is highlighted in the committee's report and in the submissions that were made to the inquiry.

There are also issues about exceptional prescribing procedure, to which we need to take a more standardised and transparent approach. Various members have talked about the need to improve data and hospital prescribing. Finally, we need to explain everything to patients, and I am glad that the Government has taken that on board in its response.

I have covered those points quickly, because the heart of the debate—the big controversy—concerns co-payment. I am glad that the committee has recommended a review and that the Government will go ahead with it. I have listened carefully to what Nicola Sturgeon said about the issue on the radio this morning and in Parliament this afternoon and it seems clear to me that she accepts that there are serious clinical governance and risk issues with co-payment and that she will take those on board.

In the evidence, I was struck by a quote from Professor Alan Rodger, medical director of the Beatson oncology unit—to whom we should pay tribute as he is retiring soon. He talked about two clinicians treating a patient and said that there could be

"one in the private sector delivering one drug, the other in the NHS delivering three drugs. That is not good clinical care. It is a recipe for disaster."—[Official Report, Public Petitions Committee, 29 April 2008; c 751-2.]

I am sure that those clinical governance issues will be considered, but the heart of the matter is the fundamental issue of principle and the risk of, threat of and concern about a two-tier health service developing on the back of co-payment.

We all have sympathy with patients who are in the situation that is highlighted in the petition, and members are aware of patients who come to the committee or to our surgeries who are in that position, but it is important that we exercise our imaginations today and look ahead to a situation in which the guidance is different. In that regard, I think Jackson Carlaw's speech has been the most useful in the debate so far, because he described the future that will arise if we go down the route of co-payment. Members should read his speech and reflect on the consequences of that approach. If we go down that route, another group of patients will come to us with their concerns.

There will be a situation that does not exist now in which patients are side-by-side in beds in the NHS and one is getting one treatment while the other gets a different treatment because he or she can afford it. Not only poor people but many people on modest incomes will come to us and ask, "Why shouldn't I get the treatment that's available to someone else?" Members need to reflect on that.

We should also listen to the cancer charities, which have reflected seriously on the matter. I am sure that we have all read the briefing from Cancer Research UK, which says that co-payment

"has the potential to create more problems than it solves."

We all received what is perhaps an even stronger submission against co-payments from Macmillan Cancer Support today. Yesterday I talked to a senior cancer clinician who gave the same objections. We must think long and hard about the issue. It will be interesting to hear what Mike Richards comes up with in his review in England, but we have to take a Scottish view. My current view is that we should be very wary of co-payment, but we should certainly take all the other necessary actions.
October 1st 2008, (Columns 11350-2)