The public must be allowed in to meetings where vital decisions are taken about which new drugs are available on the NHS in Scotland, according to a landmark review.
Health boards have also been told to be more transparent about the way they choose which medicines doctors can prescribe and how they handle requests from patients for drugs which have been blocked.
Even some doctors do not fully understand how to apply for a treatment which is not on the approved list under the current system, says the report.
The independent review of access to new medicines was ordered by the Scottish Government after criticism of the availability of ground-breaking treatments north of the Border.
A range of cancer specialists, including consultants from the Beatson in Glasgow, told the health committee of the Scottish Parliament that Scotland offered an "inferior health service", with patients being denied life-saving treatments that are available in other parts of the UK.
Two reports are being released today in response. One looks into the Scottish Medicines Consortium (SMC) – the quango equivalent to Nice in England which agrees which new drugs health boards can prescribe after weighing up the benefits and costs. The other looks at how health boards implement the SMC'S advice.
The SMC is praised for being efficient and robust, but the report by Professor Philip Routledge of Cardiff University says it does not recognise "ultra-orphan" medicines – those for people with very rare conditions affecting fewer than 100 patients in Scotland.
It says the SMC should have a special policy to deal with these treatments, which can be more expensive because low usage leaves drug companies struggling to recoup research costs.
It adds there should be a "citizens jury" to advise on where society feels priorities should lie when it comes to funding new drugs.
The SMC, which has continued to meet in private while Nice and the Welsh equivalent have open forums, is also told to meet in public.
The report says: "Patients and patient group representatives can observe how the patient voice provided by their submissions contributes to the discussion, and those working in the NHS or pharmaceutical industry can observe the rigour of the scrutiny being applied to the sources of evidence."
Professor Charles Swainson, former medical director of NHS Lothian, who has looked at the health board side, is more critical. He says: "Inside the NHS there are sound guidance and examples of excellent arrangements that are marred by inconsistency, failure to fully follow guidance, and a mixed picture of availability of transparent and easily accessed information."
He quotes research showing 74% of medicines accepted by SMC are put on health boards' prescribing lists. Why the other 26% do not make the frontline needs to be investigated, he adds.
Mr Swainson wants the area drug and therapeutic committees (ADTCs) responsible to publish their decisions and make them easily available on websites, and for national meetings to be held to agree the way forward for some new drugs nationwide.
While he rules out scrapping ADTCs, he says they need to work hard to demonstrate "improvements in access to new medicines and public reporting of their work".
The system by which patients can apply for treatments blocked by the SMC should be the same Scotland-wide and audited publicly, the report says. Doctors should be trained and supported to help them use it.
Health Secretary Alex Neil said: "I am proud that Scotland has among the fastest and most efficient medicine review processes anywhere in the world. However, we cannot overlook concerns of clinicians, charities and patients about access to medicines.
"This independent review provides key recommendations on how to improve access arrangements for new medicines in Scotland to make them better than ever before."
It is understood that the Scottish Government will take into account any recommendations following the inquiry into access to new medicines before responding to the reports. Any changes proposed will be subject to consultation.
Mr Neil said: "Many of the recommendations focus around making sure the system is open and transparent, and I want everyone to have their say on how we make sure Scotland has the best system possible."
A £21 million fund to cover the cost of medicines for patients with rare conditions has already been launched.
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