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The 13 cancer drugs paraded by National before the election were never intended to be a definitive guide, writes oncologist professor Christopher Jackson who co-authored a 2021 report to highlight the gap in available cancer drugs between NZ and other countries.
Inform your opinion: There are few of us lucky enough to walk through life unaffected by cancer. Whether it be a parent, a spouse, a friend, a workmate, or even ourselves, cancer has touched us all.
Most of us know someone with an incurable cancer who has learned that there might be a drug that could keep them alive longer but isn’t publicly funded. A drug that could keep them alive for another anniversary, another birthday. To get to a family wedding, to see a child go to school or to be born. Cancer drugs represent hope; hope that we might get a little bit more time to do those things that matter most in life. Just one more day.
Pharmac has often been painted as the villain in this situation, as the gatekeeper that decides who gets funded drugs and who does not, like some dystopian pharmaceutical version of The Hunger Games. Its black box and notoriously opaque processes leave patients, advocates and doctors frequently flummoxed by funding decisions. Patients have few avenues other than media pressure or Givealittle pages to access the drug that gives them that once last chance, that one last hope.
Behind the scenes, pharmaceutical companies charge increasingly exorbitant prices for cancer drugs whose cost seldom bears relationship to their benefit. Some newer agents are priced at more than $50,000 a month. At that price, you’d expect to buy an outcome like Lazarus, yet the data often shows the majority who take them derive no benefit at all, except for perhaps hope.
There have been very few occasions where politicians have played as directly on this hope as occurred in the lead-up to the 2023 election. National announced it would fund 13 specific cancer medicines, ostensibly not picking winners because “the Cancer Agency chose them”, not the politicians - all they did was offer hope.
That was until the Budget. There was money for pothole repair and landlord tax exemptions but nothing for those seeking respite from cancer as promised in year one of a National-led government.
Suddenly, it was too hard, there was work to be done, and the solutions were to be worked through with a curiously indefinite time frame. National already knew these problems – it faced them when it promised to fund Herceptin in the 2008 election campaign and had to deliver outside Pharmac once it became government.
There are two distinct questions when it comes to public drug availability. The first is how much to spend. That’s a matter of budget and therefore relative priorities for government funds. The second is how to best spend the allocated money, and it’s where politicians have largely stayed out.
Pharmac has been the firewall behind which many a politician has hidden, stating that it is not being heartless, it is merely the powerless agent against the advice of the experts and tough decisions have to be made.
In my opinion, National circumvented the separation of those two questions. By picking “winners” it aimed to satisfy the loudest and most emotional demand for drugs, painting itself as saviour, while circumventing a process for fairest allocation of resource in a constrained system. It struck a Faustian bargain, and when it came time to pay, it failed to deliver.
It could re-write the law and instruct Pharmac to fund the specific drugs of its pre-election pledge. It has the electoral mandate, but it would breach the independence firewall and invite open season for lobbyists and single-issue advocates to exert public and media pressure to usurp the dispassionate process that is Pharmac, a process that ensures that even the quietist voices are heard.
Funding a specific list also undermines Pharmac’s ability to leverage down prices by playing competitors off against each other in an auction that the lowest bidder would otherwise win. When it extracts the lowest price, there is more money for others to benefit.
It could uplift Pharmac’s baselines to a point whereby the 13 made the cut. However, this would certainly be more expensive, as those drugs promised at the election are unlikely to have been Pharmac’s top picks.
It could set up a specific cancer drugs fund, as happened in the UK, but this prioritises cancer medicines over other drugs. While appealing at first glance, it doesn’t take long to consider that drugs for cystic fibrosis, debilitating neurological conditions or crippling arthritis are not equally or possibly more life changing.
While Pharmac has flaws (oh, it has many), the better question is whether a different model would deliver better outcomes through more medicines for more people for the same or lower cost. I think the answer to that question is no.
The other complexity is that the list of 13 was never intended to be a shopping list for politicians to parade and purchase. It came from a 2021 report that I helped write that intended to highlight the gap in available cancer drugs between NZ and other countries, and to evaluate how meaningful that gap was overall.
The drugs helped people live better and longer, but few were cures. It aimed to inform, not to instruct. More, and better, drugs are now available overseas. That 13 is no longer the actual need or the real gap.
As an oncologist who sees people affected by cancer every day, I think we need more cancer medicines. I also think that cancer medicines cost too much, and we’re being rorted by Big Pharma. I think Pharmac is good but imperfect. I think politicians should stay out of picking drugs to fund. All these things can be true at once, and taking an entrenched view will risk an untoward outcome.
People place a high premium on more quality time at the end of life. As Kiwis, we think it’s unfair that people should have to sell their homes or drain their savings to have a little more time with people they love. That’s what we think we pay taxes for. It is important to us that we have hope, because without hope we have nothing. And when hope is promised, when people vote for hope, and when that hope is snatched away, the voting public have every right to be angry.
Professor Christopher Jackson is a medical oncologist and Professor of Cancer Medicine, University of Otago, Ōtepoti Dunedin. He was an expert advisor and co-author for the Cancer Agency’s medicines availability gaps analysis. The opinions expressed in this piece are his own.
