KEY POINTS:
It is not just the suffering that New Zealand patients go through because of the lack of availability of new generation drugs that is disturbing, says Professor Mike Findlay - the lack of investment also has a knock-on effect on the country's clinicians.
At the Royal Prince Alfred Hospital in Sydney, where Findlay worked for much of a decade, hospital doctors are constantly designing and running clinical trials - and have higher job satisfaction because of it.
"There's that sort of buzz happening. It's partly because there's more money in the system, and the [pharmaceutical] industry does support it more."
Here it is less exciting. The latest figures from the OECD's 2007 Health at a Glance study, which compares the health statistics of the world's rich countries, back Findlay's comments. Australia ranks 5th out of 25 OECD countries in pharmaceutical spending over the decade 1995-2005 (6.4 per cent). New Zealand has the second-lowest growth (2.5 per cent) in the developed world.
The report also points out that this is a risky strategy, given that many modern pharmaceuticals have the ability to keep people out of hospital and ensure they are healthy, contributing members of society.
Australia and many other countries, outstrip New Zealand's performance by several other measurements of overall health, including deaths from heart disease, cancer survival, respiratory illness and more.
Professor Harvey White, the director of coronary care and cardiovascular research at Auckland City Hospital, maintains New Zealand's high overall death rate from constricted heart arteries is related to our lower spending on newer heart drugs.
New Zealand's death rate for cancer, now the country's leading cause of death, is also significantly higher than in Australia and partly caused by our limited access to modern treatments such as Herceptin and implanted radiotherapy, which are both available there.
New Zealand's pharmaceutical strategy, based around the drug-buying agency Pharmac, is unique. We are the only country in the world that has a fixed drugs budget. And although that budget is adjusted for inflation, in real terms it has actually reduced slightly - from $673 million in 1997 to $600 million last year. Meanwhile, pharmaceutical inflation has been running hot and New Zealand's overall health budget has grown by almost $4 billion.
GP Pippa MacKay, who is also chairperson of the Researched Medicines Industry Association, says: "Under this system, when a new product becomes available Pharmac will say, 'Yes we'll fund it but it has to be cost-neutral'. [So] another drug has to be taken off the list to let it happen."
This, says MacKay, puts our patients and clinicians under unnecessary stress. "I think Pharmac in general has been over-zealous," she says. "But what I blame is Government policy. You don't see too much agitating for drugs from Pharmac or the DHBs. I find it excruciating that people come into New Zealand with drugs that I can't give them here. I have to tell them, 'Sorry, but I can give you a less potent alternative that may give you more side effects - but it's very cheap!"'
Professor Findlay, 47, and a senior member of the gastro-intestinal cancer team at Auckland City Hospital, is concerned about the level of care he can offer his patients.
"If we felt the public system offered a reasonable deal, ran efficiently and gave a good clinical service, that'd be great."
And does it?
His answer is surprisingly blunt for an academic at pains to emphasise New Zealand cancer care has made some progress since he returned from Sydney in 1998. "No."
"Although we're now better off compared to Australia than we were five years ago, there are inevitable funding limitations, especially around new drugs. At this snapshot some drugs are available in Australia but not New Zealand. One, called rituximab (also known as Mabthera) is given for primary lymph node cancers, (lymphoma). There's now pretty strong evidence that it's bringing great improvement to people with very low-grade lymphomas. People don't ever get cured of them [lymphomas] but this drug can double life expectancy. The catch is, despite the improvement in survival, Mabthera is too expensive to achieve Pharmac's cost-benefit threshold."
Findlay is also concerned that Pharmac's attitude is discouraging clinical trialling here. "In Australia drug companies routinely offer new drugs on compassionate access programmes," he says. "This way hospitals trial drugs free on the assumption they will be paid for when funding comes through. Here, Pharmac says, 'If you start the drug, the drug company has to finish it, so even if we approve it in the future we're not going to fund all these new patients who have already started it on a compassionate programme'.
"The problem is, the companies say, 'Hell, we're really being screwed down here. Why bother?"'
Overall, says Findlay, "Australia has a greater commitment to improving healthcare rather than saving the dollar. We have too many Pharmac committees, too much focus on cost and too many hold-ups. We're still evaluating drugs that have been around for a year or two in Australia.
"Pharmac also has a strong emphasis on drugs that improve cure rate rather than the length and quality of patients' lives. Cancer is now becoming more like a disease people live with, like diabetes. We're keeping people with cancer alive a lot longer now."
For all the criticism, the medical director of Pharmac, Dr Peter Moodie, is convinced they are doing a good job. Pharmac does lobby for a larger share of the health cake, but he is not upset at its lack of success. "New Zealand can be proud. We have one of the most efficient systems for funding pharmaceuticals in the world."
He points out their methods have driven down costs: "We have a very aggressive policy about older drugs when they go off the patent list. We're looking for a very significant saving."
In Australia, waiting lists for urgent cases are non-existent and more drugs are fully funded. Here, although waiting has improved since 2002, when three months to be seen by an oncologist was standard, there are still problems.
Even now the wait for an appointment at Auckland Hospital is four to six weeks - and two to four weeks after that before treatment starts.
"If you've got a stomach cancer the chance of you being alive in three months is pretty low," says Findlay. "It's a long time."
PUFFING - FOR A PRICE
Despite her childhood asthma, Brenda Cottle climbed mountains in her 20s. Now the 74-year-old suffers dreadfully on humid or cold days - unless she is using her Spiriva inhaler. Part of the new generation of drugs for people with Chronic Obstructive Respiratory Disease, Spiriva is expensive. Here it is funded only for people who have 60 per cent or less of normal lung function.
For Cottle, her free sample of Spiriva was "marvellous". But when she applied for on-going inhalers she was refused. "I was definitely eligible, but I kept getting turned down, even though I had [lung function] tests," she says. "All sorts of forms needed to be filled in. Apparently my doctor hadn't done it correctly."
After a year of paying $120 a month for her inhalers, the restrictions were lifted. Today the grandmother of three is back at classes in yoga and callisthenics, walking her dogs and leading a full and active life.
As Asthma New Zealand's Gerry Hanna points out, Pharmac does not make things easy for the one-in-four children and one-in-six adults who suffer from asthma.
Singulair, which comes as a child-friendly chewable pill, and has been available in Australia for years, arrived here only late last year. Seretide, a combination puffer that delivers an inflammation-reducing drug plus a longer-acting "preventer" is still difficult to access. "This is one of the most important advances ever in asthma," says Hanna. "And here it's only available after three months on the two-puffer option."
Even Australian patients, who have been stable on Seretide for years, must go back to two puffers for three months before their doctor may prescribe it. A nebuliser loaded with Ventolin nebules was taken off the free list and replaced by one using another nebule. "Once again Pharmac has replaced something that was working smoothly with something that doesn't work but is 20 or 50 cents cheaper."
The bid to drive Ventolin nebules out of the New Zealand pharmaceutical landscape is part of a continuing campaign. Back in 2005 Pharmac replaced Ventolin with a cheaper generic called Salamol. The problems were instant: children reacted badly to the taste of Salamol's alcohol-driven puffers. Some parents chose to part-pay the $7.10 to $19 for Ventolin inhalers, some children refused their medication.
"The point is," says Hanna, "Every time a child ends up at Starship hospital it costs us, the taxpayer, around $5000."
