• Second donor stem cell transplants no longer “affordable” for the NHS despite being “routinely” funded before 2013
  • Leading oncologist calls NHS England’s clinical prioritisation process “not fit for purpose” and says decision “flies in the face” of global expert opinion
  • The specialist treatment was given “lowest cost/benefit priority” status despite offering a 30 per cent, five year survival rate

Patients with blood cancers are being denied lifesaving transplants under new NHS England funding rules, despite these surgeries being “routinely” funded prior to 2013.

NHS England’s clinical prioritisation advisory group, which reviews funding requests for specialised treatments, decided last month it will no longer fund second donor stem cell transplants as they are “not currently affordable”.

Blood

Blood

The CPAG will reconsider funding the treatment in the next prioritisation round

Richard Davidson, director of engagement for stem cell transplantation charity Anthony Nolan, told HSJ: “If you deny a second transplant it is very likely that those patients will die.”

Professor Charles Craddock is a member of the NHS England specialised services clinical reference group for blood and marrow transplantation, which recommended the treatment to the CPAG, and director of the blood and marrow transplant unit at University Hospitals Birmingham Foundation Trust. He said: “We used to routinely commission a procedure in common with almost all other developed health economies and we are now unable to deliver that – you have to say that there is a problem with the [prioritisation] process.”

Professor Craddock described the prioritisation process as “not fit for purpose”. He added: “There is a consensus of opinion by responsible expert haemato-oncologists in the UK and across the world saying this [treatment] is important but we having a funding process that flies in the face of that.”

The transplant is the final treatment option for patients with blood cancer who have seen their condition relapse after a first stem cell transplant from a donor. It used to be funded via local commissioners but was not included in permitted treatments when the specialised commissioning process was centralised under the Health and Social Care Act 2012.

To help resolve this omission, the treatment was one of 22 considered by the CPAG for funding in this financial year. In its recommendations to the advisory group, the bone and marrow transplantation clinical reference group estimated 16-20 people a year are in need of this specialised procedure, known as a second allogeneic transplant, with 184 patients receiving one between 2000 and 2009. It said approximately 30 per cent of patients can live for more than five years following a second transplant.

However, last month NHS England confirmed the procedure and two unrelated treatments would not be funded in 2016-17 as they offered the “lowest/cost benefit priority and are not affordable”.

An NHS England spokeswoman said the “intervention is not routinely offered on the NHS due to its relatively low success rate”.

Jenny Byrne, president of the British Society of Bone Marrow Transplantation and a member of the CRG, said: “I find it impossible to understand why they thought of it as the lowest priority.” She said prior to 2013, Nottingham University Hospitals Trust, where she is a haematologist, had been undertaking second stem cell transplants for more than 20 years, adding: “I don’t think in their evaluation of the cost benefit ratio [the CPAG] realise how much money is needed for patients needing palliative care treatment. I don’t think that is fully taken into consideration how much it is costing us not to do these transplants.”

To make it to the CPAG panel each proposed treatment has to be deemed clinically effective by its representative CRG. The panel then looks at the “incremental benefit” of the treatment alongside the “incremental cost” and ranks them accordingly. These recommendations are used to inform commissioning decisions by the specialised commissioning oversight group, before being ratified by the specialised services commissioning committee of NHS England.

Anthony Nolan has also raised concerns about this decision making process, calling it “very crude” and “subjective”. Mr Davidson said: “It is not clear to me that it has been taken into account that this is a curative treatment of last resort, as opposed to one which improves or extends life…

“The fact that we are talking about very small patient numbers is part of the problem, because it becomes more difficult to get robust data on both cost and effectiveness.”

Since 2013, NHS England has recommended patients in need of a second allogeneic transplant apply for funding via individual funding requests. However, Anthony Nolan said only around six a year are granted for this treatment and the charity expects this to be reduced as the IFR process is being reviewed in a separate consultation. No patients at either Dr Byrne’s or Professor Craddock’s trusts have successful received IFR funding for a second transplant.

Dr Byrne added: “It’s a hideous situation [to deny a patient the treatment] especially as they may be sat next to a patient in clinic who had their second transplant in 2012. It is totally unfair.”

The CPAG will reconsider funding the treatment in the next prioritisation round for 2017-18, however Professor Craddock said: “The clinical community does not have great optimism that there will be a reversal of this decision.”