These commentaries by John Macgill represent his opinions only and not those of any Ettrickburn client.

Cost of medicines falling

Three Nations Three Practices

Community Pharmacy Eliminating Hepatitis C

Homeless People make Glasgow

Heart Failure – we can get treatment right for everyone

Bundles of Safety

Community Pharmacy’s Leader in Scotland

CPO: On the Road to Achieving Excellence

Pharmacy technicians may become prescribers

Profile: Dr Norman Lannigan OBE

Profile: Jonathan Burton MBE

Profile: Clare Morrison MBE

Deep Dive Pharmacy

Mind the Gap - Diagnostic Skills for Pharamacists

Bundles of Safety

Supporting Excellence - Alison Strath Interview

2018 Pharmacy Forum Agenda Launched

Which Referendum to Choose

Three Perspectives on Pharmacy and Mental Health

Pharmacy and the New GP Contract

Bordering on Problematic

Recognised by the Queen and her community

VACANCY Reporter/Researcher: Health and Care Policy in Scotland

Prescribing in Mental Illness – A Practice Pharmacist’s Perspective

What Matters to You? Communication in Pharmacy

Prescribing in Mental Illness – A Patient’s Perspective

Focusing the Vision: Dr Rose Marie Parr on the new strategy for Scottish pharmacy

All the things that could go wrong - looking ahead to the SNP conference

Ask Once, Get Help Fast? Pharmacy and Mental Health

Automation and Delegation in Pharmacy: Understanding the Moving Parts

Initiatives Highlight Potential of Community Pharmacy

Pharmacy First in Forth Valley One Year On

Trying to concentrate on the day job

Health and the Local Elections – a strange silence

The Pharmacist Will See You Now – The Growth of GP Pharmacy

Montgomery’s Review – Dr Brian Montgomery answers questions on access to new medicines in Scotland

An afternoon with SMC

Pharmacists at SMC

SMC – are drug firms voting with their feet?

Radical Surgery on the Horizon for Scotland’s NHS

The Future’s Bright – in General Practice

Community Pharmacy in a Changing Environment

Disclosing payments to doctors – has Sir Malcolm done the pharma industry a favour?

Health and Care in the First Minister’s Programme for Government

CMO: Scotland’s pharmacists “absolutely ideally placed” to practice Realistic Medicine

Profile: Maree Todd – MSP and Pharmacist

Scottish Parliament Health Committee Work Programme

Scotland’s new NHS – a Summer of Speculation

Scotland’s New Health Committee

Two million voices in Scotland – is integration the big opportunity to listen?

Medicines – levelling the playing field

Key appointment raises the bar for health & social care partnerships

What did our new MSPs do before?

SMC says no then NICE says yes – three times

SNP promises single formulary and a review of Scotland’s NHS

More Generous than the CDF – but less transparent

Comparison of Funds: New Medicines v Cancer Drugs

Bonfire of the Boards? SNP signals NHS Review

A tribute to five retiring MSPs

New Medicines Review - Health Committee sends findings to Government

Medicines New & Old in the Scottish Cancer Strategy

Great Ambitions, Slow Progress – New Models of Care in Scotland

Scottish Minsters Demand Up-Front Medicine Price Negotiation

Opportunity and Disappointment: MSPs Investigate New Medicines Access

Scottish NHS Strategy calls for 'Realistic Medicine'

The Scottish Model of Value for Medicines: Taking Everything into Consideration

When SMC Says No: An Access to Medicines Lottery

Reviewing the Review: Access to New Medicines in Scotland

A day of psephology and kidology

Insulting the Lifesavers

Worthy of Mention – Health and Science in the Honours List

News Silence from North of the Border

A Christmas PPRS Present from Pharma

Thursday, March 17, 2016: Medicines New & Old in the Scottish Cancer Strategy

The Scottish Government’s new cancer strategy is broad and far-reaching, with a vision for new medicines and plans to redeploy old ones.

Beating Cancer: Ambition and Action[i] is described as the blueprint for cancer care in Scotland over the next five to ten years. It encompasses prevention, detection, treatment, research and continuing care.

It offers a warts and all assessment of what has yet to be achieved to join up services and improve outcomes – and to address the cancer survival divide between Scotland and our neighbours, and between different communities within Scotland. The ambitions, plans and committed extra investment are impressive.

So, to home in on one relatively small aspect of the strategy – what it promises in terms of the role of medicines – is to look at just a few pieces of the jigsaw.

For medical oncologists and the medicines industry the message from the Strategy is that medicines have an important role in treatment alongside surgery and radiotherapy.

The Government says it is committed to improving access to new medicines – at a fair price – and then to scrutinising their real world performance. Ministers also state their commitment to the NHS in Scotland supporting the entry of new precision medicines both through clinical trials and molecular pathology services. Most controversially, perhaps, the Government says it wants to pursue a policy of examining how off-patent medicines can be ‘repurposed’ for the treatment of cancers for which they were not originally licensed.

In the Strategy, ministers look forward to the recommendations this summer from Dr Brian Montgomery’s review of access to new medicines processes, committing the NHS to continuing to ‘evolve’ the appraisals system.

Reiterating the Health Secretary’s recent evidence to the Parliament’s Health and Sport Committee, the Strategy’s section on access to new medicines states:

 “Fair pricing of cancer drugs remains a challenge and we will consider our systems to ensure that Scotland gets best value. We also need to do more in taking a systematic approach to whether new medicines deliver the value that has been shown in clinical trials. We are supporting a project led by NHS Greater Glasgow and Clyde on the clinical effectiveness of cancer medicines in a real life setting.”

The Strategy goes on to state:

 “While the focus is often on new medicines, the increase in repurposing of older off-patent medicines presents opportunities for improved outcomes. Unlike newly licensed medicines there is currently no comprehensive approach to assessing repurposed off-patent medicines and recommending their use across Scotland. There is a need to ensure that we are well placed to maximise the opportunities of these medicines and therefore work will be undertaken to establish what improvements can be made to our current approach.”

Late last year a Bill tabled at Westminster to give Whitehall responsibility for repurposing off-patent medicines into unlicensed indications fell after failing to get UK government support[ii].

Labour MP Nick Thomas-Symonds had sought to create both a duty and a mechanism for the UK Government to license off-patent medicines for new uses where justified by the evidence. Thereafter, he envisaged, the National Institute for Health and Care Excellence (NICE) would appraise them and ensure widespread uptake by the NHS if appropriate.

In a statement on the Bill[iii], the medicines industry trade body, ABPI, pointed out that ministers could already ask NICE to undertake technology appraisals of unlicensed medicines in certain exceptional circumstances. ABPI went on to state:

 “The Department of Health does not believe that the barriers for patients in such instances are primarily about licensing. In the debate in the House of Commons on 7 November [2014], the Minister for Life Sciences, George Freeman MP, said that: “In this landscape, the restraining factor is the lack of information for clinicians about off-label use. We need to encourage greater off-label use through NICE, and to have a culture within our health system that actively supports it”.”

At the other end of the spectrum, Scotland’s First Minister last month committed £4 million to support the development and commercialisation of precision medicines. This development, the new Scottish cancer strategy says, has the potential to transform healthcare:

 “It is expected to bring benefits for individuals and for the health service alike by reducing the risk of wasteful and ineffective prescriptions, providing better and more effective personalised treatment to individuals, tailored to their genetic makeup and the particular characteristics of their disease.

“By knowing the whole genome sequence, it may be possible to offer a diagnosis where there hasn’t been one before, understand better the cause of disease and work out how best it might be managed.”

The Government promises that the remit of the Scottish Cancer Research Network will increase as part of a national commitment to “increase, support and sustain clinical trial activity in cancer”.

The importance of evidence from real world data, including the feedback from patients on their care and wellness, is a recurring theme:

 “To make certain treatments and care is rooted in evidence, we will work to improve the data we collect, analyse and publish, to better reflect the experiences of people with cancer. We want to embed research in the ethos of our healthcare services – allowing individuals access to and participation in clinical trials appropriate to their circumstances. We will underpin and support this work by establishing a new cancer intelligence system to provide high quality, timely information for clinicians and individuals at all stages of their cancer journey, and by funding vital research.”

The Scottish Government’s assessment is that, while it is addressing access to new medicines in cancer, “challenges remain in providing equitable access to high quality surgery and radiotherapy”.

The new cancer strategy is meant to have a shelf life of between five and ten years. In the world of cancer medicines innovation, this is a very long time. It is possible that the whole treatment model for some cancers will have changed before then.

In the light of recent research, the model (in some cancers) of surgery first and most expensive medicine last may no longer offer patients the best pathway.

Cancer Research UK-funded work by university and NHS teams in Manchester and London[iv] published last week showed a “dramatic” effect of using a combination of two medicines for women with HER2 positive breast cancer during what the study called “the window between diagnosis and surgery”. The use of trastuzumab (Herceptin) and lapatinib (Tyverb) was shown to shrink the tumour rapidly. In some cases, it disappeared.


[i] Full Strategy

[ii] Pharma Times Report

[iii] ABPI briefing November 2014

[iv] CRUK news release