Health committee  What time period are you thinking in terms of the investment? Over a decade, I think yes, you will, but—

Health committee  Yes. Ten years from now, I think you would see real differences in the utilization of emergency care services by the socio-economically....

Health committee  I'm quite a fan of what the Netherlands do, actually. I think the U.K. does lots of good things, but it also has a very long history, which constrains things it wants to do. It has a very, very big formulary, containing about 25,000 different things. The Netherlands kind of started later, and actually I think they've been pretty smart, so I would go look at the Netherlands.

Health committee  I would agree. CADTH would be an excellent lead organization to put that together. Very briefly, what a health system pays for is an expression of a society's social values. You can't just pick up somebody else's, because it's about what Canadians value. There's going to be a large overlap, but you're going to have to be sensitive to social values around the edges.

Health committee  I think in the orphan-drug space, the prices of these technologies are so high that relatively few people have the ability to sustain the premiums they have to pay. I think as a general principle, medicines for severe orphan conditions should be on the essential medicines list and should be provided publicly.

Health committee  We did it in the U.K. It's probably the best example. If there's one thing I'm really proud of in the U.K., it's NHS' outstanding specialist commissioning program, which I think has genuinely been world-leading. They used it to drive up standards and reduce variations in the package, and therefore the quality of care.

Health committee  Informally, and correct me if I'm wrong, these networks kind of exist, but they don't necessarily get the resourcing support they need to really leverage the benefits. I think if you go to those informal communities and ask who the best people are and what optimum care would look like, and back that up with contracting and resources, I think they'll tell you what it should look like, but with national resources rather than provincial or territorial resources; it's much more feasible than in our current siloed world.

Health committee  There is still uncertainty, but it is of a level where the cost of doing the research to reduce that uncertainty further, both in terms of health gain foregone from delaying general access and the direct cost of running the study, is less than the value of the uncertainty. It is just a bigger issue for rarer diseases, and that is why we have to [Inaudible—Editor].

Health committee  I'd like to reiterate that in those international relationships and through collaboration, a national pharmacare can not only contribute data, but that frequently with orphan drugs the companies control almost all of the evidence that's available. By having a national pharmacare that negotiates, you can negotiate not only price, but also the site of the data they hold and accumulate through their registries, to help Canada more rapidly get an understanding of the true value.

Health committee  In principle, conceptually, the comparison is the same as for a conventional therapy. The difference is about the level of certainty or uncertainty, the risk that what you observe in the trial is not actually going to be observed in practice when you roll it out to more patients.

Health committee  With having such a large domestic pharmaceutical industry in the U.K., it's obviously a major concern whether the restriction of access would actually impact upon investment and innovation in the U.K. I would observe first of all that the initial analysis done by the U.K. Office of Fair Trading established, as many others have, that there isn't actually a relationship between pricing behaviour and inward investment for the pharmaceutical industry.

Health committee  It depends on whom you ask. If you ask NICE, they will tell you they have turned down only two cancer drugs in all of their history. If you ask the cancer community, they will say they have turned down 40-odd. The difference is that NICE will count.... If we say yes to a specific subgroup that is not all clinically indicated, we are saying yes.

Health committee  I believe it was with the establishment of the NHS in 1948.

Health committee  It was a time of transition. Rudolf Klein did some work in the mid-eighties and looked at historical records. There was undoubtedly a transaction cost, because you had a culture shift. In the first couple of years, from 1948 through 1950 to 1951, if I remember rightly—it's a long while since I've read the book—you saw a real spike in prescribing levels.

Health committee  I'd like to start by thanking you for the invitation to speak today. You probably notice from my accent that I'm from the U.K., and much of my experience and insights into a national pharmacare program I have derived from 20 years' experience as a health economist advising the NHS on paying for drugs.