The UK Coalition Government: Cancer Strategy

18 Aug 2010

By Clare Sansom

The first coalition government in the UK since the Second World War has now marked a hundred days in office. What has this dramatic change in the country's political landscape has to offer the cancer community?

Coalition governments have been the norm in Continental Europe for decades and in the UK's devolved governments since the late 1990s. Working with the Scottish Government and Welsh and Northern Irish assemblies has shown Jon Spiers, Head of Public Affairs at Cancer Research UK, that, almost regardless of the parties involved, coalitions have some advantages over single-party governments. "We need to be thoughtful and pragmatic, and build relationships with people who we know to have different perspectives", he says. "Smaller coalition partners – like the Liberal Democrats in Westminster today – can often help to push issues up the agenda".

An analysis of the two governing parties' manifestos and the Coalition Agreement, however, reveals relatively few details of what the next five years are likely to hold for the UK's cancer community. The word "cancer" appears seven times in the Conservative manifesto, twice in the shorter Liberal Democrat one, and three times in the even shorter coalition agreement. Spiers has, however, been very encouraged by the response to CRUK's "Commit to Beat Cancer" pledge, launched in the run-up to the 2010 election campaign. "We asked all prospective parliamentary candidates to support commitments in five priority areas: cancer detection, prevention, and treatment; tackling inequalities in cancer incidence and outcomes; and protecting the UK science research base", he says. "We are pleased that 260 of the 650 members of the new House of Commons are signed up, and that the pledge has completely cross-party support."

Media coverage of cancer-related issues during the election campaign itself focused on a single issue: the Conservatives' flagship policy, the Cancer Drugs Fund. There had already been much discussion of NICE decisions not to recommend expensive cancer drugs (often kinase inhibitors) that are in widespread use in other European countries. One cause célèbre reported during the election campaign concerned a 37-year-old kidney cancer patient, who chose to pay personally for a course of Pfizer's Sutent™ (sunitinib) and who has since died. The Cancer Drugs Fund, which is included in the coalition agreement, initially offered £200 million from April 2011 to fund drug treatments for cancer that are not otherwise available on the NHS; some funding will now be made available from October this year. "Consideration of funding requests under the Cancer Drugs fund will be a matter for local clinically-led panels based on the advice of cancer specialists", says Paul Burstow, Minister of State in the Department of Health and a Liberal Democrat. However, even this fund is only designed as a stop-gap; in the longer term, the Government intends to move towards a system of "values-based pricing" as recommended by the Office of Fair Trading in 2007. In this, prices for drugs would be set on the basis of an explicit assessment of their clinical value, in contrast to the current system that gives a much freer rein to the pharmaceutical companies to set their own prices. Richard Barker, Director-General of the Association of the British Pharmaceutical Industry, likes the broad strategy but is concerned about how, or even whether, it will be made to work: "the devil is in the detail". Barker's concern about how a values-based pricing system would work in practice is widely shared, and doctors also worry that the interim Cancer Drugs Fund might give even more power to the pharma industry. In an editorial in the 12 August issue of the British Medical Journal, Martin Duerden wrote that "This suggests, at least in the short term, that drug companies can charge what they think fit and the NHS will pay regardless",

And this new money for cancer drugs needs to be seen in the context of the harshest economic climate for at least a generation. "The budget deficit is an enormous challenge for government", says Spiers. "Realistically, it would have been the first priority of any government of whatever party taking office this year." Protection of the current level of NHS spending, however welcome, makes a harsh change from the increasing budgets of recent years. Nevertheless, charities and pressure groups are beginning to cast their recommendations in terms of economic efficiency. The Lancet recently published results of a large-scale clinical trial showing that a nationwide programme offering a flexible sigmoidoscopy screen to everyone once between the ages of 55 and 64 could prevent up to a third of cases of colorectal cancer, and cut deaths from the disease by as much as 50%[1]. "This should be cost-effective in the long term", suggests Spiers. And, with delayed diagnosis recognized as one of the principal reasons behind the UK's poor performance in cancer survival statistics when compared to similar countries, there is a clear need for clinically proven early interventions such as this.

The Government published its health White Paper, Equity and Excellence: Liberating the NHS, in early July. This set out the intention of moving towards evaluation through "clinically credible and evidence-based outcome measures", such as cancer survival rates. On 6 July, Burstow announced that he had asked Professor Sir Mike Richards, the National Cancer Director (or, colloquially, the "Cancer Tsar") to review the 2007 Cancer Reform Strategy in order to "to ensure that we have the right strategy, subject to the Spending Review, to deliver improved survival rates". This is a laudable intention. But even with the Department of Health spared the 20-25% cuts that most departments envisage in that spending review, the harsh economic climate must challenge the ability to deliver an improvement in outcomes.

A wide-ranging epidemiological study by Bethan Thomas and co-workers[2] has recently shown that concerted efforts by the previous government have not dented inequalities in either income or health: in fact, inequality has risen throughout the first decade of this century. Thomas quotes the 2010 Marmot review[3]: "If society wishes to have a healthy population, working until 68 years, it is essential to take action to both raise the general level of health and flatten the social gradient." Burstow talks of ending inequalities mainly in terms of promoting "public awareness of the signs and symptoms of cancer", and lifestyle changes for all, rather than of interventions to directly "flatten the social gradient". Since almost every type of "risky" behaviour – smoking, eating and drinking to excess, and inactivity – increases with lower socio-economic status, this may well be a sensible approach. However, it remains to be seen how it will be implemented, and here signals are mixed. The government's commitment to introducing minimum pricing for alcohol is to be welcomed, but some useful interventions from the previous government are being scaled back or cancelled. The Walk England scheme has been cancelled and the Food Standards Agency is being scaled back with a sole focus on food safety. Most controversially, perhaps, health secretary Andrew Lansley rejected celebrity chef Jamie Oliver's high profile campaign to improve school food as "hectoring", and the "evidence-based" strategy he proposes as an alternative remains very unclear.

It is also unclear how the fifth of CRUK's priority areas, "protecting the UK science base", will fare in the spending review. Cancer researchers remain in something of a privileged position, and the public's financial support for cancer charities has remained high even through the depths of the recession. Spiers looks forward to the launch of the UK Centre for Medical Research and Innovation that is planned for central London. This, the largest medical research laboratory in Europe, will have a strongly translational focus; its founder director, Nobel Laureate Sir Paul Nurse, will take up his position on 1 January 2011. Yet funding for basic research remains very vulnerable, and this must underpin all translational medicine.

Deputy Prime Minister Nick Clegg has urged the British public to judge the government on its whole five years, not just the first hundred days. Its cancer policy has drawn ideas from both coalition parties; it may be bold and interesting, but it risks being undermined by budget cuts. The devil will truly be in the detail.

[1] Atkin, W.S. et al. Lancet 2010; 375: 1624–33

[2] Thomas, B. et al. BMJ 2010; 341: c3639

[3] Marmot M. et al..Fair society, healthy lives: the Marmot Review Executive Summary. Marmot Review Team, 2010.