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PrEP for HIV…now what?

PrEP for HIV rolled out nationally would, on the figures I have seen, cost less than the NHS spends on dandruff and paracetamol. Much, much less. But does that make it a good investment?  The only way we will find out is through a proper, transparent and robust prioritization process.

The Court of Appeal ruling today means that will now need to happen. The Court has dismissed NHS England’s appeal. It upheld much of an earlier judgment which NHS appealed against. The full judgment needs studying but the effect of the ruling will be that NHS England needs to put PrEP through a fair, transparent and proper prioritization process.

NHS England immediate response

This has been met by a disappointingly grudging and obfuscating release from NHS England https://www.england.nhs.uk/2016/11/update-on-prep/

I’ve blogged elsewhere including in Local Government Chronicle that of course we understand NHS England has to prioritise, the point is it needs to do it fairly and transparently. The tactics over PrEP were distasteful, condemned by charities representing patient groups they tried to play off against one another and, unfortunately, has now cost an awful lot of taxpayers money to confirm what most of us first contended.

NHS England’s news release among other things said three things about the judgment, some of which miss the point:

“First, it establishes that NHS England has the ability but not the obligation to fund PReP.”  Actually that’s been the contention of most of us all along. This is a redundant point.

“Second, it means that should we decide to do so, we would not be subject to legal challenge on these grounds from rival ‘candidates’ for specialised commissioning funding.” Indeed. but the contention of many of us is that NHS England needs to face this fair and square through a proper, transparent and methodologically robust prioritization process. Waving round threats about legal action from others isn’t going to let NHS England off the hook from doing this properly. And NHS England seems to be slow to learn that this is just what happened – NAT and LGA took legal action and NHS England lost. So the point of all this, surely, is prioritise properly and fairly.  Otherwise we’ll end up back in court.

“Third, it overturns the High Court in helpfully clarifying that Parliament did not intend that the NHS was expected to fund local authorities’ public health responsibilities just because they have not done so.”  This is entirely beside the point and is a tenuous reading of the judgment. The point is NHS England CAN , contrary to their argued position, commission prevention initiatives. They contended all along they couldn’t. Let’s not start re-writing the history of the case and its particulars now NHS England have lost.

Things to remember during the coming months

Throughout this and what comes next, we need to remember the following key points:

  • NHS England are up against it financially. But so are local authorities. Working together, not resorting to legal action, is the way forward.
  •  As I said above, PrEP will cost much, much less than the NHS currently spends on Paracetamol, and dandrfuff!  And it will, in cost-return terms, save more. It makes, on the face of it, economic sense.
  • The bigger prize, and a prize the health economic literature is starting to address, is the effect of investing in PrEP to stop the epidemic and end new transmission in England effectively.
  • Fair and equitable prioritization needs to be a key process in the future of health and social care. Time to start now.

The wider issues

Importantly, it is established that NHS England has preventive powers, including powers to prevent HIV and commission drugs like PrEP. This is a victory for good sense and a joined up health and care system, which should put prevention at its heart. This decision makes good sense

  • for the taxpayer, because it enables an intervention that will save more than it costs to be commissioned
  • for people, because we have another powerful tool in the armoury of HIV prevention
  • for a strategy to end HIV transmission in England, which is now within our reach, but only if we work better together, and use PrEP as one of the many tools to achieve that

What’s next?

It’s time to draw a line under this and work together to deliver a joined up HIV and sexual health system, which is what the taxpayer has a right to expect. NHS England has said today:

“In the light of the Court ruling we will therefore now quickly take three actions. First, we will formally consider whether to fund PreP. Second, we will discuss with local authorities how NHS-funded PreP medication could be administered by the sexual health teams they commission. Third, we will immediately ask the drug manufacturer to reconsider its currently proposed excessively high pricing, and will also explore options for using generics. We expect to be able to update on these developments shortly”

That’s immensely welcome, on all fronts.

I think most of us realize times are tight. And NHS England is right that we need to prioritise. My point all along is that their chosen tactics were a poor way to do it. It’s time now for everyone to come to the table, work together, and set about fair prioritization.

Work still to be done?

The work of doing a proper, fair and thorough prioritization process now must begin. This will need to evaluate, fairly and transparently, all the data in favour of PrEP and all the data against, as well as date in favour of other contender interventions.  And it will need to compare them, fairly, on a like for like basis.

Having been involved in health care prioritization for many years, up to and including judicial review, the real work starts now. What has happened hitherto has been a tactical game.

It may be the decision is still to prioritise something else, but a few of us are coming together to make sure we subject the NHS process to as much scrutiny as we can possibly give it. The health economics appraisal, the statistical appraisal, the comparative cost-benefit appraisal and the process of decision making will all now be subjected to intense scrutiny. NHS England played the game of “we’ve had legal advice we cant commission this” then played the game of “other candidates might sue us”.

The only safe way forward is a methodologically robust, transparent, equitable and fair prioritization process.

I, and many others, will be watching this with intense interest.

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