So much for debate on rejection of cancer drug

I would like to tell you how they arrived at this decision. In fact I should be able to. Under new arrangements intended, presumably, to improve transparency, I was at the meeting where the decision was made and heard the so-called discussion about Kadcyla take place.

Sadly, the exchange of views was limp at best. Full credit to Ian Crichton, a man called Robert (it's impossible to read all the names at the table) and chairman Professor Jonathan Fox, who made attempts to have some kind of debate.

But there were 21 people with a vote there and the vast majority did not speak. Mr Fox said in a press release about the process: "The decision to not recommend a life-extending medicine is never taken lightly."

In this instance I wonder how he knew, for I have been repeatedly reassured there was no in-depth discussion about Kadcyla behind closed doors, out of earshot.

Now, of course, the SMC has been making cost-benefit judgments about medicines for years. I understand there will be shared values and a technical language which I, a layman on the sidelines, will not be privy to.

But Kadcyla was one of the first end-of-life treatments to come before SMC after Scottish Government reforms to improve access to new medicines.

The changes include the SMC receiving a report from a Patient and Clinician Engagement (Pace) group that is meant to give both a stronger voice in decision-making.

Alison Campbell, who read the Pace report, did a sterling job representing the group's views, which were strongly in favour of Kadcyla. "This medicine gave women a normality to their life and this contrasted sharply with what would be expected with a diagnosis of metastatic breast cancer," she told the meeting.

However, because no-one responded to the points being raised by the few who spoke, there was no attempt to tease out the value SMC will place on the Pace testimony. Nor did members discuss whether more should be paid for this medicine because it helped dying patients, or weigh up the experts' view, presented in document form, that this is an effective drug in an area of unmet need, against the price tag.

I am not saying the SMC should have approved Kadcyla. While trials show it can extend life by six months, it costs £90,000 per patient. In many ways I should be writing this column on the way drug companies price their products. But it is somewhat difficult to do that when the SMC doesn't talk about that either.

I've taken an interest in the SMC for many years and was given to understand their decisions were based on a robust interrogation of the clinical evidence and cost-benefits analyses.

To be present for such a key decision and witness nothing of the sort was disappointing. The NHS as it stands is becoming unaffordable. The public at large needs to understand money spent on hugely expensive drugs represents an opportunity lost elsewhere, and rational decisions have to be made.

That way they can help shape future spending priorities. But if the members of the SMC aren't prepared to talk when the most high-profile drug to come before their open meetings arrives on the table, why would they expect wider society to do so?

If this is the way it is going to be, let's not pretend we have increased transparency with Pace and public meetings. The SMC can do the whole thing by round-robin emails and save clinicians travelling time.

I've been told SMC is just getting used to the new public forum. Come on; this change was announced in May 2013 and introduced last spring. Toddlers settle into nursery more promptly. As an outsider, it feels like members are still clinging to their mother's skirts, whingeing: "I don't want tooooo."

Apparently, the debate about another breast-cancer drug at their most recent meeting was better; too late for Kadcyla, though, and Kadcyla mattered.