The Pharmafocus Interview: Karol Sikora, Doctors for Reform
pharmafile | December 20, 2006 | Feature | Sales and Marketing | Doctors for reform, Karol Sikora, NHS
Karol Sikora, is one of the UK’s leading cancer specialists and a high-profile exponent for radical change in the NHS.
A member of Doctors for Reform, a free market think-tank/pressure group, Sikora has spent much of 2006 speaking out against current practices in the NHS he sees as unsustainable – from the rationing of expensive cancer medicines and the opaque nature of NICE, to the way the government has introduced private competition to the health service.
In criticising the ‘monolithic’ NHS and its outdated practices, his views seem to echo current Labour policies – but Sikora and his fellow medics at Doctors for Reform are far more radical, and want to challenge and overturn even the most sacred beliefs of the NHS.
Neither Labour nor the Conservatives are currently challenging the central NHS doctrine that services should be ‘free at the point of care’ and equal for all. But Sikora says the cost pressures from new technology – especially from new drugs – and the ageing population means that the doctrine must be swept away, not only because of budgetary limits, but to deliver the consumer-style service people now expect from public services.
This means some kind of co-payment for services must inevitably be introduced, including for the supply of new, high-cost medicines. “The NHS is very much a religion, and sometimes at Doctors for Reform, it’s like we are sitting there in Canterbury Cathedral plotting to throw God out,” laughs Sikora.
“No other country has this almost religious belief in their healthcare system. I think that’s because it is free; and it worked very well when it started, there’s no doubt, but it’s a product of the mid-20th century and it has to be modified.”The model he outlines is close to several European insurance-based systems such as France and Switzerland, which have more extensive competition between public and private healthcare providers.
“We have to open the NHS up to real competition – not this synthetic version of competition,” he says. “We are now spending over £90 billion on the NHS, compared to £33 billion 10 years ago, and yet the quality of care we are getting is not three times as good.“Spending levels have reached the same as France, Germany and Switzerland and yet the services here are much poorer because they are based on an old public sector model.”
PCTs as competing health insurers
Sikora observes that all Labour’s reforms have been made to the delivery of care – fast-track surgery centres for example – but he advocates opening up competition in the insurance element of the NHS. “We all currently pay a premium, which is related to our earnings and goes into a pot. The pot is administered by a series of PCTs some [of which] must be better than others. There is no talk at the moment of any opening up of commissioning to competition, but that’s clearly the logical next step.
“For instance, I live in Beaconsfield, so I belong to South Bucks PCT, but [given the right information] I might rather pay my money into a PCT where I work.
“One could see a market opening up where you could choose which PCT you go with, and then allow them to compete with each other as insurers.“Then you also allow them to offer other co-payment insurance services. So let’s imagine if I get cancer I want to have the BMW of cancer drugs, not the usual rubbish. I will pay another £100 a year now, so at any point in the next 20 years I can access that.”
Sikora acknowledges that this re-organisation would involve new costly bureaucracy, but says that cost is already present. “We are already paying that cost, but we are not getting any value from it. The problem is that PCTs come to different conclusions. If you take cancer drugs, there is a huge variation. NICE is supposed to set a standard, but even in the NICE approved drugs there is huge variation in uptake.
“There is no reason that there has to be a public insurer – why can’t the Norwich Union, for example, take a bit of the business? They will have to compete and show that they are just as good.” He concedes this would require a large-scale insurer, which would be at risk of going bankrupt if it offered to pay for the latest cancer drugs to any patient who needed it.
The best healthcare in Europe
So, which national healthcare systems does Sikora believe the UK can learn from?
“The French and the Swiss models seem to be more satisfactory for the patients. I have been to a lot of British hospitals recently and I’ve also visited French and Swiss hospitals. You go through the front door and they are completely different places from NHS hospitals.
“France, Germany and Switzerland all have private and public insurers, and there are lots of them. They also have co-payments – they may be relatively small, but people know the costs of these drugs.” He says even the NHS’s supposed ‘flagship’ hospitals such as the newly opened University College Hospital and Chelsea and Westminster Hospital are both dreary and tired when you get inside. “You go in and instantly think ‘NHS’ again,” he says, a phenomenon he believes has its roots in the fact the NHS still sees patients as service users and not as customers.
Sikora says the consumer market approach is the only way to truly bring the NHS up to expectations. “In every other walk of life, people are used to getting good customer service in a very competitive market environment – mobile phones, budget airlines and so on.
“We need exactly the same in healthcare – a new approach which allows co-payment, and rapid, convenient services. So if you want to see a doctor at 10 o’clock at night, you can, but you will have to pay more for it.” The equity or fairness of the current NHS is often named as one of its best features, but Sikora says healthcare equity can be achieved through a private model. He says the mobile phone market is a good example – even the poorest members of society have mobile phones, he says, thanks to the market competition driving down costs.
But how do Doctors for Reform propose to bring about these changes in the NHS when most healthcare professionals are against greater privatisation and, more importantly, most of the electorate are too?
“It will be a slow transition,” admits Sikora, and says one reason for this slowness is the vested interests and silo mentality of the NHS professions which have been allowed to build up.
“Nurses, doctors, radiographers, pharmacists, all have their own little power base, and getting them to work together on changing processes is difficult, because they keep looking at their own concerns.”
High-cost drugs
The NHS is facing the same problems as all other healthcare providers in the developed world, that of ageing populations and the high costs of technology. Sikora says speciality cancer is the classic example of this and adds the costs are beginning to escalate out of control.
“It’s not that anyone is ripping anyone off, that’s the cost of R&D, that’s the cost of developing these drugs. But the benefits of these drugs will be relatively small to start with and the NHS can’t pay for everyone to have them.” So does he think that Herceptin, probably the biggest high-cost drug controversy ever in the UK, is a cost-effective treatment?
“No, probably not. It shows the importance of political tinkering with the system, and that’s something no health service can really afford. “Herceptin was the exception because the ministry agreed to provide it even before it was licensed and before NICE had made its assessment.
“And that was just the political element – it’s a vote loser not to make it available. So the government overrode the whole NICE process, which is very unfortunate.”
Avastin and Erbitux, two new drugs for metastatic colorectal cancer have both been turned down by NICE, but Sikora believes the institute will eventually say yes to the drugs when they get the adjuvant (early use) indication because then they are likely to show greater cost-effectiveness.
“The problem we have got with NICE as a rationer is that it is not transparent. It claims that there is no monetary cut-off, but there clearly is – it is about £30,000 for adjusted life year saved. “I can’t see why we can’t be more honest. An economist could tell you that we spend about £90 billion on healthcare today and by 2008 it will probably be over £100 billion.”
He says the fact that drug costs account for a relatively small proportion of the NHS budget is frequently forgotten.
“So how much extra would it cost to approve all those drugs? Well it would probably be about £1 billion extra to come up to the same standard as Western Europe. You have to factor that in.” He says NICE’s opaque decision-making has a clear knock-on effect for pharma companies and patients.
“If you are in the industry, you ask ‘What do I have to do to get this drug through?’” Sikora makes it quite clear he believes the industry uses patient advocacy groups to their own ends.
“What they do is unfortunate – [they] use the patient advocacy groups, and campaigners like ‘the Velcade Three’ and Herceptin patients.
“These people are just being manipulated by PR agencies who are working for the industry. And they are also being manipulated by [opposition] politicians who create a fuss and barrack the current lot [the incumbent government].
“So instead of making the NHS a rational market, you turn it into a political football
He says these trends will be one “worrying feature” that will only be accentuated when patients are the direct consumers of new medicines through the co-payment he advocates.
Sikora is also critical of Cancer United, a recently launcehd pan-European cancer pressure group funded entirely by oncology specialists Roche.“If you look at the website, it looks OK, but it doesn’t state clearly that it’s not a charity as such. It is completely funded by Roche and organised and run by their PR agency.
“In reality, we know those doctors who took part aren’t going to promote anything that is not in keeping with Roche’s selling of high-cost drugs.”
NHS customers confronted with cost
Sikora says opinion polls build up a good picture of how the British general public perceives healthcare, and believes it reveals how ‘free NHS care’ detaches us from the real healthcare economics and difficult moral issues.
“When you conduct public surveys you find some very strange things. One survey asked the general public how much of the NHS’ money should be spent on two different types of cancer patients – a smoker with lung cancer and a 40 year-old woman with breast cancer and three children.
“Eighty per cent said the NHS should spend whatever it takes for the woman with breast cancer, while the figure for the lung cancer patient came out at about £20,000.
The very fact that a majority of the public would spend whatever it takes on breast cancer, that’s crazy. You can’t do that – the NHS would go bankrupt.
“So, the politicians have a difficult job in having to dampen down expectation all the time.” Following through on the co-payment idea, Sikora says he is somewhat bemused by the campaign protesting against NICE’s decision to stop funding Alzheimer’s drugs on the NHS for most patients.
The drugs are low cost – just £2.80 a day, so if they personally believe the drugs work, they can just pay for them themselves, he says. “Some of these people are heavy smokers – they would be spending more on cigarettes than they would the drugs! I think it is part of this mindset that every thing comes from the NHS.”
He concludes by saying patients and the public have to become more involved in making decisions about healthcare priorities for themselves. “Would you rather spend that £2.80 on a pill, or would you rather spend it on extra nursing, or a bus trip to the seaside? I think those are difficult dilemmas, but ones we will have to face up to.”
Biography
Karol Sikora is Professor of Cancer Medicine and honorary Consultant Oncologist at Imperial College School of Medicine, Hammersmith Hospital, London where he was Clinical Director of Cancer Services for 12 years.
He is Scientific Director of Medical Solutions PLC, a cancer diagnostic company supplying services to the NHS and private healthcare customers.
Sikora is a founding member of Doctors for Reform, a free market think-tank/pressure group formed in 2002.
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