Kindness and priorities

The announcement of development handouts to Māori in the regions coincide with Waitangi celebrations. See Waitangi – inclusion, protest and handouts.

Perhaps there will be a big announcement on cancer drugs for World Cancer Day (which is actually today, 4 February) – but the Government says that it is up to Pharmac (except for when the Government intervenes but they didn’t say that).

1 News: World-leading breast cancer expert calls on Pharmac to make two new breast cancer drugs more affordable

Pressure is mounting on Pharmac to make two new breast cancer drugs more affordable, as a world-leading expert says New Zealand is falling behind other developed countries in its treatment of advanced breast cancer.

Auckland woman Wiki Mullholland has been pushing for better treatment of advanced breast cancer since she was diagnosed in May.

The mother of three is lobbying Pharmac to fund new medicines Ibrance and Kadcyla.

“Advanced breast cancer is all about treatment. We need to know what’s coming next and for me, Ibrance is next,” she said.

“It’s going to cost $7000 a month for me and my family to source that.”

Now, a world authority on terminal breast cancer, oncologist Dr Fatima Cardoso is supporting the cause.

Ms Cardoso said, “The medium survival of patients with this disease in New Zealand is about half of what it is in other developed countries. From those results, it is not good, and it needs clearly to be improved”.

The average survival after a terminal breast cancer diagnosis here is sixteen months.

“It is, for the moment, unfortunately, an incurable disease, but it is treatable and with the correct treatment, people can live for several years with a good quality of life,” she said.

Pharmac says Ibrance and Kadcyla have been recommended for funding, but for a limited group of patients.

A decision is expected by the end of the month.

Calls for Prime Ministerial kindness have been made before.

Newshub (August 2018):  Duncan Garner’s desperate plea to Jacinda Ardern over cancer funding

Duncan Garner has made an emotional appeal to Prime Minister Jacinda Ardern to review Pharmac and prevent unnecessary cancer deaths.

Cancer Society’s Dr Chris Jackson told Newshub New Zealand is lagging behind and the matter needs immediate attention.

“What’s clear is that 2500 New Zealanders died from cancer whose lives could have been saved if they were treated in Australia over the course of the last five years,” he said.

Stuff (December 2018):  Teen pleads for Prime Minister Jacinda Ardern to step in and cut strings to cancer drug funding

The teenage daughter of a Palmerston North woman with advanced breast cancer has written an open letter to the prime minister, pleading for the Government to make medicine more accessible.

Molly Rose Malton Mulholland, 17, is the daughter of Wiki Mulholland, 40, who has metastatic breast cancer, which is the most advanced stage of breast cancer. It has spread to her bones.

Molly decided to write an open letter to Jacinda Ardern, begging for Government intervention after the cancer treatments subcommittee from Pharmac put forward their recommendations for the funding applications for two life-prolonging drugs, Ibrance and Kadcyla.

The subcommittee recommended the drugs be funded, but with strings attached. Ibrance would not be funded for women who had already received hormonal treatment, and Kadcyla could be accessed only by those who hadn’t been treated with another drug, Perjeta.

The Government has stepped in on regional Māori development funding, so perhaps they could do similar on drug funding. Or, where Pharmac makes the decisions, on Pharmac funding.

Labour health spokesperson Annette King in 2015: Pharmac’s underfunding is costing Kiwi lives

It is easy to point the finger at “political interference” when it comes to the tough decisions Pharmac is increasingly having to make around funding life-saving healthcare for Kiwis.

But nothing screams ‘political interference’ like the underfunding of our most successful health model.

Allowing Pharmac to fund life-saving cancer treatments in the short term – as countries overseas currently do – will offer hope without the agency being tied to a long-term funding programme.

Labour is proposing a pool of money be set aside to fund these innovative medicines for a short period, say two years, where there is little alternative treatment available. Pharmac’s model would remain untouched, New Zealanders would be able to access new drugs as those in Australia and Great Britain currently do, and money would go where it matters most – into saving Kiwi lives.

I get it that delivering for Māori is important to Ardern and her Government.  Last year at Waitangi Ardern said “When we return in one year, in three years, I ask you to ask us what we have done for you”.

But people suffering from cancer may nor be alive in three years, or one year.

Where’s the kindness and empathy for people who are sick and dying?

 

David Clark accused of cronyism after appointing another ex-Labour MP

Minister of Health David Clark has been accused of cronyism after he appointed former Labour MP Steve Maharey as new chair of Pharmac, against the advice of officials, and without following State Services Guidelines in considering a pool of applicants.

Clark’s history shows he has been appointed to a number of positions as he has worked his way into politics and up the ladder, and once he became a Minister (in Cabinet) he has made more than one appointment that involves political connections.

Clark is an ordained Presbyterian minister and practiced as one from 1997 to 2000 (he is still a celebrant and performed a civil union for Grant Robertson and his partner in January 2009).

He started his political involvement while working as an analyst for Treasury from 2003 to 2006, and was also appointed to a number of community positions:

  • Campaign hoardings assistance, Wellington 2005
  • Advisor to Hon David Parker 2006 – 2007
  • Dunedin North Campaign Committee member and activist 2008
  • Head of College, Selwyn College, University of Otago 2008 – 2011
  • Member, Finance and Audit Committee Otago Community Trust 2008 – 2012
  • Trustee, Otago Community Trust 2008 – 2012
  • Leith Branch Membership Secretary 2009 – 2011
  • Member, Otago Forward economic development forum 2009 – 2011
  • Dunedin North LEC Deputy Chair 2009 – 2010
  • Dunedin North LEC Chair 2010
  • Member, University of Otago Vice-Chancellor’s Alcohol Advisory Task Force 2010 – 2011
  • Deputy Chair, Otago Community Trust 2011 – 2012
  • Member of Parliament for Dunedin North 2011 – current

After working his way up the Dunedin North Labour Party administration he was selected to replace the retiring Pete Hodgson and won the safe-ish electorate in 2011.

He was appointed Minister of Health when Labour took over Government in October 2017. he made a controversial appointment soon after:

ODT (8 December 2017): Hospital rebuild chairman sacked; Hodgson given job

Health Minister David Clark has sacked the Dunedin Hospital rebuild chairman and appointed former Labour cabinet minister Pete Hodgson to lead the project.

When contacted, Hawke’s Bay consultant Andrew Blair said his role as Southern Partnership Group chairman was “terminated” this week. Dr Clark told the Otago Daily Times the rebuild needed to be led by a local person.

Mr Hodgson, Dr Clark’s predecessor in Dunedin North, served as MP from 1990 to 2011, and held numerous ministerial portfolios in the fifth Labour government.

“As a former minister of health, he understands the complexity of the issues involved,” Dr Clark said.

“He is indisputably a local champion, and  . . . is well connected into health.

Dr Clark’s other move is appointing University of Otago chief operating officer Stephen Willis to the group now led by Mr Hodgson.

So Clark’s university and political connections coming into play there. This left Clark open to criticism, which he got – War of words over Dunedin Hospital rebuild

Former Health Minister Jonathan Coleman says the Government has made the “wrong move for progressing the rebuild” of Dunedin Hospital.

“The announcement of the ultimate Dunedin Labour Party political insider and former Health Minister Pete Hodgson as chair of the Southern Partnership Group is exactly the wrong move for progressing the rebuild.”

Hodgson is probably a good person for the job, but there is a risk of it being seen as cronyism.

Now this week (Newsroom) Clark accused of cronyism over Pharmac appointment:

Steve Maharey, former Labour MP and ex-Education Minister was appointed Pharmac chair on August 1 to little fanfare.

But questions are now being raised about his appointment after it emerged Health Minister David Clark went against the advice of officials in appointing Maharey.

Documents released under the Official Information Act show the Ministry of Health advised reappointing existing chair Stuart McLauchlan for a fourth term.

A report from 3 May 2018 advised Clark, “the Ministry considers sound reasons exist that support the reappointment of Mr McLauchlan”.

“Pharmac is taking on new roles that will have a significant impact on the health sector… They will require Pharmac to develop new capabilities to carry out these new roles,” the briefing said.

It went on to say: “Mr McLauchlan has performed well as the chair and it is advisable to provide for continuity during this period of expansion of Pharmac’s role. This is particularly so, given that a new chief executive has recently been appointed”.

It went on to recommend McLauchlan be reappointed for a further term of three years or, if Clark wished to change the chair, to reappoint him for just one year, while a replacement chair was sourced.

But Clark overrode that advice.

Instead, he informed McLauchlan that he would not be reappointed, and elevated Maharey to the board.

Opposition health spokesperson Michael Woodhouse said the move was “appalling,” and raised questions about the process involved.

While Clark had the right to appoint Maharey, he went against guidelines from the State Services Commission, which advises a position description be filled out and a wide-pool of applicants be sought before appointing board members.

A workflow for appointment processes from the Department of Prime Minister and Cabinet shows that the general procedure is to identify required skills and “call for nominations”.

Instead, a statement from Clark said the position “was not publicly advertised, which is within the Board Appointments and Induction Guidelines from the State Services Commission”.

Clark told Newsroom the appointment “followed the standard process for Board chairs and was signed off by the Cabinet”.

But Woodhouse said the process raised issues of cronyism.

“David Clark’s appalling move to remove the previous chair and appoint a former Labour MP to the role, all with no position description, no application process, interview, or any other input into the decision is cronyism at its worst,” Woodhouse said.

Making uncontested appointments, especially when close political affiliations are involved, are risky.

Maharey may chair Pharmac competently and without controversy, but questions could be asked about his credentials. He has been Vice-Chancellor of Massey University since he left Parliament.

He doesn’t seem to have done health as an MP. His responsibilities:

  • 1990-1994 spokesperson of broadcasting and education
  • 1994-1997 spokesperson for labour
  • 1996-1999 spokesperson on social welfare, employment, and tertiary education
  • 1999-2007 he ha\d various portfolios:
    Minister of Social Services and Employment
    Associate Minister of Education holding special responsibility for tertiary education
    Minister of Broadcasting
    Minister for Education
    Minister for Research, Science and Technology
    Minister for Crown Research Institutes
    Minister for Youth Affairs

Nothing health related – but Clark didn’t have much of a background in health either.

If there are no controversies over Pharmac (or the Dunedin Hospital rebuild) this may not be an issue for Clark, but he should take care avoiding too many accusations of cronyism.


UPDATE: more appointments with political connections from Clark – More DHB chair turnover but Health Minister says it’s not political

On Sunday David Clark announced three new board chairs for Auckland DHBs – Pat Snedden will lead Auckland DHB from June 1, Judy McGregor at Waitemata DHB from June 10 and Vui Mark Gosche at Counties-Manukau DHB from Thursday.

At least two of the appointments appear to be politically motivated with Gosche coming into the role having previously been a Minister under the former Labour-led Government.

Gosche was a Labour MP from 1996-2008.

McGregor served as the first Equal Employment Opportunities Commissioner for the New Zealand Human Rights Commission between 2003 and 2013 (two terms), appointed by Minister Margaret Wilson and replaced in the role by politician Jackie Blue (a National political appointment).

Pat Snedden was previously also a Labour appointee who says he was politically pushed by National’s Health Minister in 2010 – see Minister pushes health chief out

Pharmac funding not cut

Amy Adams and National may have been a bit hasty in claiming that Pharmac funding had been cut.

Adams is still claiming this on RNZ this morning.

That seemed odd, but Grant Robertson has pointed out that it is inaccurate.

Pharmac: Budget 2018/19

PHARMAC is pleased that the Government has announced an uplift in PHARMAC’s funding.

The Combined Pharmaceutical Budget (CPB) will be increased to a record level of $985 million in 2018/19 – an increase of just under $114.2 million on the 2017/18 CPB level.

From 1 July 2018, PHARMAC will manage all public expenditure on medicines – whether used in the community or in hospital, and this means that all remaining DHB’s expenditure will be part of the CPB.

Due to the power of the PHARMAC model, this is likely to provide future savings of around $200 million over four years for Vote Health – achievable by applying the PHARMAC model to the full portfolio of medicines.

PHARMAC will continue to invest in new medicines and technology that best meet the health needs of New Zealanders.

PHARMAC has proven its ability to return savings for the health sector, while at the same time funding new treatments, as well as managing the growth in usage of existing funded treatments.

So the Pharmac budget has been increased, and ” the power of the PHARMAC model’ means that DPB spending on drugs could be reduced by $200m.

That’s if Donlad trump doesn’t force up the international price of drugs so that US drug companies can make even bigger profits.

Dunne on the budget

Peter Dunne has posted on the budget:

Most of the reaction to the 2016 Budget has been predictable. Government supporters laud it as one of the greatest things since sliced bread, while the Opposition bemoans it as do-nothing, and as always the interest groups lament that there is not enough in it for their particular constituency.

Any Budget by any government, left or right, is a balancing act between what Ministers would like to do in their own portfolios; their parties’ priorities; and, what the Minister of Finance thinks he can pay for. Every now and then, a budget provides scope for standing back a little and looking at overall policy requirements in a particular area.

He focusses on the funding of Pharmac:

There is such an issue in the 2016 Budget. In recent years, successive governments have struggled with how to fund new innovative medicines that are expensive and may not be able to be funded within PHARMAC’s existing budget and criteria. The debate over the breast cancer drug Herceptin in 2007-09 was one such example.

The upshot was that the government made specific funding available for Herceptin in 2009. That intervention was not seen as especially successful, and so, when the issue of the melanoma drug Keytruda arose earlier this year, the government took a slightly different approach, confirmed in the Budget, of providing more funding to PHARMAC which was then able to fund the similar medicine, Opdivo.

However, both these examples raise a broader issue in the context of the new and innovative biologic medicines likely to become available in the next few years, that will not only have a profound effect on the treatment of many currently life-threatening conditions, but will be extremely expensive.

As things stand at the moment, PHARMAC would be forced to play another game of catch-up, harnessing its resources as best it can, and hoping for more funding from the government to enable the medicines to be made available to New Zealand patients. And, in all probability, it will continue that way until the next such case arises, and so on. It is neither satisfactory, nor sustainable.

We need to be developing a strategic overview of what medicines are likely to be becoming available in the years to come; what is a reasonable expectation of which of these medicines New Zealanders might expect to have access to; and, how that might be funded.

In some cases, there may be other medicines available that could be cheaper and just as effective, while in other cases it might be that the particular medicines are not of as much value here as might be claimed elsewhere. And we also need to be brave enough to determine the point at which long standing medicines should be moved on, either to a part-charge regime, or to no subsidy at all, because they have been replaced by newer products.

At the present time, we have no such overview, and, as the Herceptin and Keytruda debates show painfully, governments have been left to react, when it is often too late. A more proactive approach focused on what are reasonable expectations for New Zealanders to have of the national medicines system would enable governments and PHARMAC to prioritise spending better, and would give patients a certainty they lack presently.

The limitations of the current system have been clearly exposed and when in government both the major parties have struggled to accommodate the demands being made.

(Part of the problem is that when in Opposition both parties have promised everything to everybody on the medicines front and then become hoist by the own foolish petard when elected to office. As recent events show, that puerile pattern seems likely to continue.)

A more strategic approach would prevent repetitions of that hypocritical tomfoolery, but, more importantly, would give New Zealanders a greater level of certainty than they enjoy now.

Little under fire – immigration

A day after receiving an onslaught of criticism over his ‘stiff arm’ comments on legislating banks on interest rates – see Little’s banking ballsup – Andrew little is again under fire for comments about restricting immigration, in particular his reference to ethnic chefs.

And this is after recent suggestions that Government should instruct Pharmac on which drugs to fund.

A Little twiddling with drugs, bank loans and immigrant chefs is not a good governance model.

Little and Labour appear to be in some serious trouble.

Little has made himself an easy target for political opponents – who have taken the opportunity to blast and ridicule him – but when commentators like Barry Soper call Little’s comments ‘cringeworthy’ then there’s a major problem with where things are going.

Andrew Little’s cringeworthy immigration cap

He stood comfortably enough, legs apart with feet firmly planted on Parliament’s red carpet and proceeded to put his foot in his mouth, although he seemed to be unaware of it.

It’s hard to know what’s come over Andrew Little this week but something certainly has. A couple of days ago he was leaving us in no doubt about what he’d do about banks sitting on their stacks of cash, refusing to take the Official Cash Rate lead from the Reserve Bank Guv and lowering their mortgage rates.

He’d pass a law forcing them to cut the rate as the Guv had done, although he didn’t say whether that same law would force them to raise it when the central banker did the same with the OCR.

Little’s now banging on about immigration, saying the tap should be turned down to a trickle until economic conditions improve. If he was sitting behind John Key’s ninth floor Beehive desk he says he’d put an immediate cap on immigration.

Ethnic restaurants should be hiring Kiwi Indian and Chinese chefs rather than bringing them in from overseas. And the Labour leader, who’s recently positioned himself and his reluctant caucus on the opposing side of the Trans Pacific Partnership argument, used the free trade agreement with China to reinforce his point. The agreement Labour negotiated allows Chinese chefs to work in this country and those of us who enjoy good Yum Cha would say thank goodness for that.

Little says he singled out chefs because it’s just one example of semi skilled migrants taking jobs that could be filled by Kiwis which doesn’t bode well for his next meal out if that’s the view he has of chefs.

In case he hadn’t noticed, unemployment fell against all expectations in the final three months of last year.

And much of the ‘immigration’ spike is due to New Zealanders returning to their country.

It’s hard to know why little has taken to immigration. It could be his union instincts wanting to protect ‘local’ workers.

It could be trying to compete with NZ First for anti-immigration votes – or it could be trying to get onside with Winston Peters with coalition options in mind.

Little says he didn’t bring the specific topic up:

Ethnic chefs story truly weird. NZ is a great place because of diversity. Subject was raised by journalists, not me.

Labour’s policy on immigration unchanged. We’d moderate flows according to economy. We’re a nation built on immigration.

Whatever the reasons for Little’s apparently impromptu policy suggestions he is creating serious problems for himself and for Labour.

Little has tried to repair some of the damage:

Andrew Little responds

The way comments made by me have been reported are baffling. Of more concern, however, is that they may have offended anyone. I would never want for anyone in this country to feel they are being somehow targeted. That’s not what I stand for and it’s not what Labour stands for either.

I was asked last week by the Hutt News when I visited Lower Hutt about apparent concerns locals had with immigrant chefs. As I recall, I pointed out the China FTA specifically allows Chinese chefs to be recruited for Chinese restaurants and there was a case for other ethnic chefs to be recruited on the same basis.

I said at some point I would expect with larger ethnic communities that chefs would be able to be recruited within New Zealand. I said there was an issue with semi-skilled people being recruited under skills shortages categories but I doubt whether this related to chefs.

I was asked about Labour’s policy on immigration generally. I said our approach was that as the economy slows there is a case to “turn the tap down”. I also pointed out ours is a nation built on immigration and that people bringing skills here from all parts of the world is essential for us.

I was asked about the same issues today by other reporters. I again pointed out the right under the China FTA to have Chinese chefs recruited into New Zealand. I repeated my statement about the immigration tap being turned down as the economy slowed. I said how important immigration was to New Zealand.

So, to be clear, Labour’s policy on immigration hasn’t changed. We need to moderate our intake at times when we are struggling to find jobs and houses for newly arrived folks as well as locals.

I will always support a progressive immigration policy and welcome all people who want to make a future for themselves and their families to be part of our beautiful country.

The problem with moderating our intake is that controlled immigration can be managed consistently, but the Government can’t control New Zealanders going and returning.

This week Little has suggested that the Government have their hands on interest rate taps and immigration taps. Last week he wanted to dictate to Pharmac what drugs they should fund.

Labour also seem to want to  prop dairy farmers up or somehow fix international dairy auction prices.

Coercive and reactive twiddling with drugs, bank loans, immigrant chefs and milk powder is not a sensible way to govern.

I wonder if Little is using internal polling to try and chase populist support? If so he’s making a hash of it.

Herceptin versus Keytruda

National overruled Pharmac on Herceptin in 2008, and now say it was a mistake for them to interfere.

Is the Keytruda issue different?

D’Esterre comments at Dim Post:

The Herceptin argument was, as I recall, about how long a course Pharmac should fund, not whether or not it would be funded. In the case of Keytruda, it comes (or not) into an environment in which there is no effective treatment beyond excision of melanomas in the very early stages, before there has been any spread of the cancer cells. As things stand right now, once the lymph nodes are affected, one might as well go home and put one’s affairs in order.

I’m unable to be dispassionate about this issue: like many New Zealanders, I’ve had friends and family die of malignant melanoma. It’s a cruel disease, that takes people very quickly – unless diagnosis is in the very early stages. Then they might get a bit of a reprieve.

In my view, the justification is greater for government intervention on Keytruda than it was for Herceptin.

Obviously it’s different if you get melanoma or you know someone who gets it.

But there’s a key difference between the two drugs as far as making a quick decision by Pharmac.

Herceptin was already approved by Pharmac, the change was to the length of time it was taken for.

Keytruda is not just an new currently unapproved drug that Pharmac says needs to be researched thoroughly before they approve and fund it’s use. It is one of the first of a new class of drug.

Some caution has to be taken in approving a totally new drug. Unfortunately for some people in life threatening situations that requires time. It has to take some time.

If Pharamc approved and funded a drug that was found to have as yet unknown serious side effects there would be even more angst directed at Pharmac and the Government.

Like and death issues are very difficult to deal with and care has to be taken to ensure the best choices are made.

Hague pawn apology but makes key points

Green health spokesperson Kevin Hague has apologised  for saying sick people were lobbying pawns for the pharmaceutical industry – there’s some truth to that but probably not worded as well as it could have been.

But he makes the key points about needing to separate political interference from Pharmac decisions and that underfunding was the real issue.

Radio NZ: Green MP apologises for drug pawn comment

Yesterday, melanoma sufferers and their supporters delivered a petition signed by over 11,000 people to Parliament, calling for funding for immunotherapy drug Keytruda.

Mr Hague said he was wrong and insensitive to suggest the sufferers were pawns.

“I don’t regard those people who came to Parliament yesterday as pawns. If I was in their position, I would have done the same thing,” he said.

People with life threatening illnesses who can’t get access to drugs that may save their life are in an invidious position. But being used by pharmaceutical companies or by politicians to try and pressure a non-political entity like Pharmac is tricky.

He had been trying to make the more general point that if politicians intervened in Pharmac’s drug funding decisions it would create an environment where drug companies would focus their attention on publicity campaigns, he said.

“What I am criticising is the actions of politicians from several sides who have indicated that they would definitely fund this drug.

“As a politician, it’s clear that that would be a popular decision … but it would be the wrong thing to do.”

New Zealand’s pharmaceuticals budget had been underfunded by hundreds of millions of dollars and that was where the political focus should be, Mr Hague said.

That’s exactly where the pressure should be applied.

Health Minister Jonathan Coleman says he is pushing for more funding in the upcoming budget, and opposition parties should be helping promote his case.

But demanding instant changes to Pharmac decision making – that has to be careful from  cost and from a health angles – using dying people is not helpful to those people who may think the action might suddenly change things for them.

The Keytruda problem

It was sad to see people with cancer being used to try and put emotional/political pressure on the Government and Pharmac. There will always be insufficient funds for all possible drugs and medical treatments.

One of the worst things that could happen to Pharmac is for it to become a regular political football. Drug decisions have to be made at an arms length to the Government and even further distant from the Opposition parties.

Pharmac has provided an explanation of how their Keytruda decision making process goes:

Clinical review of pembrolizumab (Keytruda)

A summary of advice to PHARMAC and the application process

Executive Summary

  • Pembrolizumab (Keytruda) is a treatment for patients with advanced melanoma. It is a new way of treating cancer and therefore holds promise. As a very expensive new treatment PHARMAC needs to know whether that promise will be realised.
  • PHARMAC has rapidly assessed the application for providing public funding, and received advice from experts in the field of cancer treatment and data interpretation.
  • According to current data most people who receive pembrolizumab for malignant melanoma will not see a response in their tumours. Of those people that do get a response, it is not clear at this time whether pembrolizumab will help them live longer.
  • The data is not conclusive, but does signal a level of effectiveness in a cancer that has previously had very few treatment options. Our expert advisors recommend pembrolizumab as an option for funding, but not ahead of other medicine funding options that offer a better balance of evidence and price.
  • In order to address these issues PHARMAC will be working with the pharmaceutical company on the future data availability as well as potential commercial solutions.

What is PHARMAC looking at?

PHARMAC is assessing an application to list pembrolizumab (Keytruda) on the Pharmaceutical Schedule. This is a new treatment for melanoma for which the clinical evidence is still emerging. The application from Merck Sharp & Dohme seeks funding for pembrolizumab for people with advanced melanoma (metastatic or unresectable Stage 3 and 4 melanoma). Medsafe, New Zealand’s medicines regulator, approved pembrolizumab for this use in September 2015, and there are other clinical trials underway testing it in many other types of cancer.

There has been strong public interest in this medicine; however, there is a gap between the public’s perception of the benefits offered by pembrolizumab and the measured benefits seen in the clinical trials to date. While it is not unusual for a public relations campaign to hope to influence PHARMAC’s funding decisions, we follow a robust process to ensure that we are fair to all patients waiting for treatments to be considered and that we make good decisions on the next best spend of the health dollar to the benefit of all New Zealanders.

Who do we get our clinical advice from?

In our funding assessments we first seek advice from the Pharmacology and Therapeutics Advisory Committee (PTAC), which is made up of 12 senior doctors and pharmacologists who are experts in reviewing and interpreting complex clinical data on pharmaceuticals. We sought advice on pembrolizumab from both PTAC and its Cancer Treatments Subcommittee (CaTSoP), a specialist committee made up of nine independent cancer specialists with expertise in treating people with cancers, including melanoma. Obtaining objective advice from clinical experts provides assurance to New Zealanders that we have carefully considered the relevant evidence for how well a medicine works, for which patients and in which illnesses.

What benefits were shown in the trials?

The trials show pembrolizumab may have some early benefits for some people and some risks for some people. In some people treated with pembrolizumab, tumours shrank or disappeared, and there was a delay in the tumour returning. In most of those people whose tumours did respond to treatment, their tumour response was maintained until the time of data analysis. In the main trial (Keynote-006), the majority of people treated with pembrolizumab either had no change in tumour size or their tumours grew. For one in three people, tumours shrank or disappeared completely and this response was maintained until the time of data analysis when half of the patients had been on the trial for 8 months or less.

No clinical trial has yet shown that pembrolizumab increases the length of life for melanoma patients compared with other new melanoma treatments or standard chemotherapy.

Are there risks?

The trials showed pembrolizumab has some side-effects, with around 1 in 10 people experiencing a severe side effect, although the clinical experts thought these side effects were manageable. Pembrolizumab appeared to be less toxic than ipilimumab, another new melanoma treatment that the Committees had previously reviewed.

What did the clinical committees recommend?

The clinical experts thought that pembrolizumab has benefits for some people, and there is a lack of currently funded effective treatments for melanoma. They recommended pembrolizumab be funded, and gave their recommendation a low priority. This is because of the current uncertainty about the magnitude and long-term durability of any benefit, together with the extremely high cost.

 

More in the PDF: Clinical review of pembrolizumab (Keytruda)

Turei and a Pharmac fallacy

There’s been a lot of speculation about Pharmac in relation to the Trans Pacific Partnership Agreement. And misinformed comment and misinformation.

In a column (MP’s View) in Dunedin’s The Star Metiria Turei wrote:

Is the TPP agreement good or bad?

There are many questions about what it means, largely because we have been kept in the dark. The agreement has been negotiated in secret and that has made it hard for everyone on both sides of the debate to really understand the impact of it.

Until the Agreement was agreed on of course it was difficult to know what the impact might be. But it was finalised and the full text was made available last year.

So now the text has been released, we can all, for the first time, really look at what is negotiated and make our own judgements.

Let’s look at Pharmac for example. There are many people who are concerned about maintaining access to free and cheap medicines.

So, we are seriously concerned about then increased cost of medicines, especially the new and better ones emerging called biologics. As more of these become available in New Zealand the cost will rise.

It’s unclear what she means by that. Of course if there are more of a group of medicines the cost of that group will probably rise.

The Government estimates a $1 million annual cost to Pharmac but says nothing about increased costs of new medicines.

It’s likely new medicines will be more expensive with or without the TPPA. Medine costs have been rising for decades.

The Government also estimates $4.5 million for the set-up cost and a $2.2 million annual cost of a process to allow Pharmac decisions to be reviewed by other agencies.

Even the most conservative analysis from MFAT shows costs rising but little benefit to sick New Zealanders needing help.

I don’t think anyone expected there would be definable benefits to sick people from the TPPA. I doubt MFAT made an emotional ‘analysis’ like that.

What they do say in Cost to PHARMAC of Implementing the Transparency Annex of TPP :

The analysis below outlines the estimated costs of operating new administrative procedures required under TPP. While these procedures will not change the PHARMAC model or its ability to fund, prioritise, approve or decline applications for funding pharmaceuticals, they do involve some cost to implement.

The actual operating cost to PHARMAC of implementing TPP is likely to be less than the estimates below, partly because PHARMAC may be able to absorb some of the activities required by the Annex within existing resources.

Estimated costs are then detailed, coming to the totals cited by Turei. But Turei doesn’t say that MFAT said that the operating costs are likely to be lower. And MFAT doesn’t say anything like “little benefit to sick New Zealanders needing help”.

And we have listened carefully to the arguments on both sides of this debate.

Medicines is just one example where the details give us all better information about the effects of the TPP agreement.

I encourage you to look a little deeper into it.

This exchange on Facebook has been circulating:

PharmacTPPAMueller

Pharmac director Jens Mueller said:

Any PHARMAC cost increases will be absolutely negligible in comparison to the total PHARMAC budget and the additional export revenues from the TPPA.

An MFAT Fact Sheet says:

Consumers will not pay more for subsidised medicines as a result of TPP. Most prescription medicines are fully subsidised and, with few exceptions, New Zealanders pay no more than $5. TPP does not change this in any way.

I wonder how carefully Turei and the Greens have listened to both sides of the argument. Turei is playing on people’s fears with little justification and only vague assertions.

Reports I’ve seen in media show little concern about the effects of the TPPA and medicine costs.

It looks like Turei is playing on a Pharmac fallacy.

 

Pharmac funding and saving lives

An interesting exchange on Twitter over the funding of Pharmac and who should choose which drugs to prioritise.

Will fund the new melanoma drug? says yes


Lisa Owen: A new melanoma drug – Annette King all but committed you to funding that. So would you?

Andrew Little: Yes

Lisa Owen: Oh are you taking over Pharmac’s job?

Andrew Little: No, ah, you know melanoma is a huge problem for New Zealand. We know that the amount of Pharmac spends over the last you know ten or fifteen years has reduced considerably. The total health budget has reduced considerably but we have this major problem with melanoma.

And a drug that we know two other countries use becasue it works, why wouldn’t we have that here. So there is a decision to take to say we need to do this.

Shame. Political decision-making on medicines a very bad idea

You’re right, it’s a big call to go in over the head of pharmac

Except that the Pharmac model is killing kiwis

Unless you want Pharmac to have an uncapped budget (do you?) there will always be unaffordable drugs that would save lives

If “saving lives” was the metric, then a lot a drugs Pharmac funds wouldn’t be funded.

Indeed

Hague is one of the most sensible and practical MPs.