In March 2015, Simon Stevens, Chief Executive of NHS England, announced the first national diabetes prevention programme. Reflecting on the potential for the NHS to reduce the future costs of diabetes care by supporting people to lose weight, exercise and eat better, he said that "if these results were from a pill we'd doubtless be popping it."
Prevention is big news in NHS England. It is as major theme of the Five Year Forward View. There is consensus that preventing serious illness is the key to a sustainable health system.
Today, NHS England was told by the High Court that it has the power to commission a pill which would prevent another serious, life-long illness: HIV. The pill in question is HIV PrEP (pre-exposure prophylaxis). When used correctly, it is nearly 100% effective at stopping people from acquiring HIV, when they are exposed to the virus through sex without a condom. In the world of HIV prevention, this is as big as it gets.
In response, NHS England announced their intention to appeal the High Court decision. It appears they don't want to be responsible for people at high risk of HIV popping this particular pill. They don't even want to be responsible for deciding whether or not to fund PrEP. NAT brought the judicial review after NHS England dropped PrEP from its decision-making process after 18 months of work. This appeal means even further delay.
Mr Justice Green said in his decision this morning:
'No one doubts that preventative medicine makes powerful sense. But one governmental body says it has no power to provide the service and the local authorities say that they have no money. The Claimant is caught between the two and the potential victims of this disagreement are those who will contract HIV/AIDs but who would not were the preventative policy to be fully implemented.'
Now we have the clarity we need to protect these 'potential victims.' NHS England has the power to commission PrEP. Why do they want to appeal this decision?
Of course, local authorities may also commission PrEP, if they decide to do so. But a national programme provided by the NHS is an infinitely better option, for three main reasons:
1. A national programme of commissioning ensures fair and equal access, avoiding postcode lotteries.
2. NHS England is in a better position to get a good price for the drugs for a national programme, compared to local authorities who would be buying for a very small population.
3. Local authority public health budgets are being slashed, year-on-year.
Reasons one and two are about good policy-making; number three is about the current, undeniable reality of local authority budgets today. No one is denying that NHS budgets are tight. But they are currently protected from funding cuts. Local authority public health budgets were subjected to in-year cuts of £200million in 2015/16 and are facing year-on-year cuts into the foreseeable future. These budgets must pay for clinical sexual health services, alongside all other health promotion efforts for their local population. Local authorities would already be responsible for providing the services which would allow people to access PrEP and get the support they need. NHS England seems to want to see drugs costs added to this list.
What are we supposed to make of NHS England's insistence that it is not legally allowed to pay for a pill that would prevent serious long-term illness? It doesn't fit comfortably with the commitment to investing in prevention which it continues to make, vociferously, elsewhere.
PrEP is exciting, new, and currently, unique. It is not a vaccine, although it has a similar impact. We can draw comparisons to statins, in terms of preventing illness, or contraception, in terms of preventing unwanted consequences of sex. But actually, there is nothing quite like it. It is the definition of healthcare innovation. The NHS should be falling over itself to get the benefits, which makes today's response all the more regrettable.