The Cancer Drugs Fund (CDF) has come under increasing financial pressure as the National Institute for Health and Care Excellence (NICE) has continued to restrict or deny access to new cancer medicines. In July 2013 the government announced an increase in annual funding from £200m to £280m for the years 2014 to 2016. However, NHS England realized very soon that even with the extra funding, there would be a shortfall this year and next.
Therefore, they decided they needed to take action. Following a short consultation process in the autumn, they introduced two measures:
- stricter criteria for the inclusion of further medicines into the scheme
- re-evaluation of some of the medicines currently funded under the scheme
Re-evaluation takes the form of a list of medicines, based primarily on ranking of the drug treatment versus others that rest on the strength and quality of the evidence of clinical impact, combined with an assessment of drug cost (the median drug cost per patient).
To place medicines in rank order in this list, the CDF is applying a “prioritization tool”. This consists of four elements:
- background information (largely procedural, but including average drug cost per cycle of treatment and median duration of treatment)
- pivotal clinical trials and key data
- new regimen compared to existing treatments
- “scoring tool”, summarized in Table 1
This represents a promising but incomplete approach towards multi-criteria decision analysis (MCDA). It suffers from two key weaknesses:
- not all the key elements are scored numerically
- scoring for one of the key elements – cost – remains confidential
The outcome – 25 indications have been removed from the Cancer Drugs Fund list, covering 16 different drugs
Of these 16 different drugs, five drugs have been completely removed and have no remaining NICE-recommended indications. They include: Zaltrap (irinotecan/5-fluorouracil/folinic acid), Jevtana (cabazitaxel), Halaven (eribulin), Tyverb (lapatinib) and Arzerra (ofatumumab). The other 11 have seen restrictions, in some cases significant, in their range of indications covered.
These numbers are sufficient to suggest that clinicians and patients placed some value on the contribution these excluded drugs were making to the care and treatment of patients.
A brief rationale for the decision made for each of the drugs assessed is available on the NHS England website.  While it details the scoring and assessments for the clinical parameters, no information about the assessment of costs is available. Thus, there is no way of identifying the extent to which cost was a factor, rather than the strength of clinical evidence.
Severe cost constraints will continue, and the CDF will have to make tough decisions on affordability
It is clear that funding for the NHS will continue to be severely constrained for the foreseeable future, irrespective of the outcome of the forthcoming general election. In that environment, NHS England has no alternative but to consider the affordability of new treatments. Adopting a process resembling multiple criteria decision analysis (MCDA) for the CDF makes sense, and is certainly preferable to NICE’s focus on the single measure of cost per QALY. But in applying MCDA, NHS England has missed some opportunities:
- the full algorithm, including the cost factors and the weighting of the different elements, should be made public and subject to consultation.
- for re-evaluation of products the accumulated evidence on outcomes should be taken into account.
- there should be clarity and transparency on the process, and particularly with regard to the opportunity for price negotiation.
Longer term, NHS England and NICE need to work together to ensure a common framework for the assessment of new medicines, and not just cancer medicines. The first steps with the NICE Highly Specialised Technologies Programme show how this might be feasible.
For further information, contact Jim Furniss at email@example.com.
 NHS England. Standard Operating Procedures: The Cancer Drugs Fund (CDF). Available at: http://www.england.nhs.uk/wp-content/uploads/2014/11/sop-cdf-1114.pdf. Accessed February 2015.
 The Economist. Letters. Available at: http://www.economist.com/news/letters/21641129-letters. Accessed February 2015.
 NHS England. Cancer Drug Fund. Available at: http://www.england.nhs.uk/ourwork/pe/cdf/. Accessed February 2015.
 NHS England. Cancer Drug Fund decision summaries. Available at: http://www.england.nhs.uk/ourwork/pe/cdf/cdf-drug-sum/. Accessed February 2015.