The E100: Biotech ex­ecs are bull­ish about 2017, but fret about drug pric­ing and the FDA un­der Trump

About the End­points 100: This is our sec­ond biotech in­dus­try sur­vey, which we sent out to our in­vite-on­ly group of ex­ec­u­tives on Feb­ru­ary 6. 98 ex­ecs, pri­mar­i­ly in the US and Eu­rope, com­plet­ed the sur­vey, You can see a list of the en­tire group at the end of this ar­ti­cle.

The biotech in­dus­try is feel­ing bull­ish about its own prospects at the be­gin­ning of 2017, large­ly sat­is­fied with the fi­nan­cial sup­port that’s been flow­ing in to the field with most ex­ecs ready to hire through the year as the tem­po on deal-mak­ing re­mains up­beat.

But it’s not all com­ing up ros­es.

The in­dus­try is in a funk about the Trump ad­min­is­tra­tion af­ter a few weeks of head­lines over a trav­el ban con­tro­ver­sy and a rolling se­ries of out­spo­ken tweets, with a large seg­ment of these ex­ecs wor­ried that a new head of the FDA could come in ready to re­duce if not ac­tu­al­ly dis­card stan­dards on drug de­vel­op­ment.

And vir­tu­al­ly no mat­ter what Trump says or does, a clear ma­jor­i­ty add, we’ve en­tered a new era on drug pric­ing that will de­mand a new math on what ther­a­pies cost. As for the high-pro­file in­stances where com­pa­nies and CEOs have been fin­gered for price goug­ing, many be­lieve we’re see­ing an end game where the re­tal­i­a­tion is like­ly to be se­vere enough to stop such prac­tices for­ev­er.

That’s the bot­tom line from our lat­est End­points 100 sur­vey, which cap­tured the thoughts of a broad swathe of CEOs and top-lev­el ex­ecs in the in­dus­try.

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Down on Trump

Ful­ly two-thirds of these ex­ecs — out of 98 who re­spond­ed to our sur­vey — are deeply dis­en­chant­ed with Pres­i­dent Trump.

Thoughts ranged from “a smol­der­ing dump­ster fire with re­gards to health and hu­man safe­ty” to “his ac­tion on the im­mi­grant ban was mis­guid­ed. His in­abil­i­ty to re­frain from tweet­ing is ar­ro­gant. His ad­mi­ra­tion of Putin is fool­ish.”

A huge ma­jor­i­ty — 82% — dis­ap­proved of the pres­i­dent’s ac­tions. On­ly 4% found some­thing to ap­prove.

One of the pres­i­dent’s sig­na­ture ef­forts ear­ly on has been to blast what he calls out­ra­geous pric­ing for drugs. A big group — 63% — feel that the bio­phar­ma in­dus­try has en­tered a new era on drug pric­ing. But a strong ma­jor­i­ty of 56% be­lieve that al­low­ing Medicare to ne­go­ti­ate drug pric­ing, as Trump has said now re­peat­ed­ly, is the wrong move.

“I be­lieve that Phar­ma re­al­ly doesn’t get it,” said one ex­ec. “Ever since the fi­nan­cial cri­sis there has been a con­stant drum­beat by pa­tients, physi­cians, etc on the price of drugs. We need to be more fo­cused on bring­ing ‘val­ue for the mon­ey.’ There isn’t enough mon­ey in the world to ad­dress the world’s health­care. We need to raise the bar much high­er for our­selves and price re­spon­si­bly. We are killing the gold­en goose.”

“Trump told Phar­ma CEOs to get prices down, in­no­va­tion up and bring busi­ness­es back to the US. He means it and I be­lieve Phar­ma will self reg­u­late on bla­tant price in­creas­es (of which many are guilty).”

On­ly 24% felt that the sta­tus quo on pric­ing could be main­tained.

“Pay­ers are al­ready in­creas­ing pres­sure and there is ex­treme pres­sure in the EU. Ex­ces­sive price in­creas­es on gener­ic drugs must stop. Need to mod­er­ate price in­creas­es on drugs gen­er­al­ly to be more in line with in­fla­tion.”


Medicare price ne­go­ti­a­tions

There’s no doubt­ing the con­sid­er­able op­po­si­tion in the in­dus­try to push­ing Medicare in­to price ne­go­ti­a­tions. But a large mi­nor­i­ty, 44%, felt that there was good rea­son for Medicare price ne­go­ti­a­tions.

“Wrong move or right move, it’s an ob­vi­ous move. It’s the biggest pay­er and some­how, some way, this will hap­pen.”

None of the sol­id ma­jor­i­ty who op­posed see­ing Medicare lever­age low­er prices di­rect­ly ex­pressed their opin­ion on it.

Scott Got­tlieb

It’s ear­ly days in this ad­min­is­tra­tion, but sev­er­al of the ex­ecs who took this sur­vey ex­pect to see some fast changes out of Con­gress, some of which will like­ly spur the M&A side of the busi­ness.

“Ex­pect repa­tri­a­tion (of over­seas prof­its) which will dri­ve more col­lab­o­ra­tion/ac­qui­si­tion. Ex­pect volatil­i­ty in com­mu­ni­ca­tion from ad­min­is­tra­tion re­lat­ing to pric­ing, dri­ving con­tin­ued un­cer­tain­ty un­til ad­min­is­tra­tion clar­i­fies po­si­tion one way or an­oth­er on pric­ing.”

“The biggest im­pact they will have will be in the ap­point­ment of the HHS sec­re­tary and the head of the FDA (hope­ful­ly Scott Got­tlieb).”

“Wild­ly un­pre­dictable. Of the var­i­ous un­knowns now the no­tion that the FDA might con­vert ap­provals to “safe­ty on­ly” is the most alarm­ing.”


The FDA

There is a sig­nif­i­cant di­vi­sion of opin­ion about what the FDA should do un­der a new com­mis­sion­er. 43% said no sig­nif­i­cant changes are need­ed in terms of reg­u­la­tions, sat­is­fied that changes made over the last few years has sub­stan­tial­ly ben­e­fit­ed bio­phar­ma and stream­lined de­vel­op­ment with­out erod­ing stan­dards.

37%, though, are look­ing for sig­nif­i­cant changes.The theme, though, sug­gests the in­dus­try is look­ing for a con­tin­ued evo­lu­tion of the reg­u­la­to­ry land­scape, fa­vor­ing de­vel­op­ers but not gut­ting the gold stan­dard on ef­fi­ca­cy and safe­ty.
“Con­tin­ue to build on ac­cel­er­at­ed ap­proval frame­work.” 

“Do not low­er sci­en­tif­ic stan­dards; re­tain safe­ty and ef­fi­ca­cy hur­dle; in­crease use of sur­ro­gate and re­al world end­points, in­clud­ing da­ta from wear­able and dig­i­tal sources to help stream­line ap­proval with more dis­ease- and pa­tient-rel­e­vant end­points of ef­fi­ca­cy.”

“FDA has been do­ing a good job. We need to keep the high ef­fi­ca­cy stan­dard.”

“I ac­tu­al­ly think over­all the FDA is do­ing a great job, I don’t think rad­i­cal re­form is need­ed. But I do think that many of the ini­tia­tives and re­forms of re­cent years have been em­braced by Sr. man­age­ment, but not by the rest of the bu­reau­cra­cy yet.”

“Ter­ri­fy­ing to think of low­er­ing ef­fi­ca­cy stan­dards sig­nif­i­cant­ly. Not good for the pub­lic or the in­dus­try!”

“In many ar­eas, reg­u­la­to­ry sci­ence is decades be­hind ad­vances in new tech­nolo­gies and med­ical sci­ence. In the rare dis­eases, for in­stance, we need a rig­or­ous yet flex­i­ble reg­u­la­to­ry frame­work that does not ex­ist to­day. The fact that there is not even a re­view di­vi­sion at FDA ded­i­cat­ed to rare ge­net­ic dis­eases is a tragedy in it­self. “

“In­creased use of bio­mark­ers, ac­cel­er­at­ed ap­proval path­ways and per­haps even the in­tro­duc­tion of ‘con­di­tion­al’ ap­proval path­ways will dri­ve med­i­cines that are proven safe and ef­fec­tive to pa­tients as quick­ly as pos­si­ble. In fact, the most sig­nif­i­cant change that could be made at the FDA is to in­clude the pa­tient per­spec­tive at every step of the drug de­vel­op­ment and reg­u­la­to­ry re­view process. Do­ing so will save count­less lives.”
John F. Crow­ley Chair­man & CEO Am­i­cus Ther­a­peu­tics

Brent Saun­ders’ pledge

One change that got a broad thumbs up from the E100: Brent Saun­ders’ call for an in­dus­try pledge to keep an­nu­al price in­creas­es on drugs in the sin­gle dig­its, un­der 10%. A to­tal of 67% en­dorsed the move, with quite a few call­ing it sen­si­ble and vi­able or “a breathe of fresh air.”

But there was al­so a de­tectable air of skep­ti­cism that this kind of ap­proach could work as a longterm so­lu­tion, with many see­ing it as a log­i­cal tem­po­rary step.

“This seems clos­er to fol­low­ing the laws of grav­i­ty than a plan. But it should cre­ate some much-need­ed day­light btwn in­dus­try and (con­tro­ver­sial Tur­ing founder Mar­tin) Shkre­li”

“I found Brent’s procla­ma­tion a bit disin­gen­u­ous… He pro­claims he wilre­spon­si­ble on pric­ing but then takes 9.9% across his en­tire port­fo­lio. Re­al­ly! What in­dus­try gets 9.9% price in­creas­es?”

“I would say that we should em­pha­size ty­ing price in­creas­es to in­fla­tion in some way. If in­fla­tion goes to 15% you would not raise prices by 9% and if in­fla­tion is 1% you would raise less than 9%. I wor­ry about dog­mat­ic state­ments like “sin­gle” dig­it which do not take in­to ac­count the macro eco­nom­ic is­sues.”


The pulse on biotech prospects in 2017: Run­ning strong

This is the sec­ond sur­vey that is keep­ing the thumbs on the pulse of in­dus­try con­fi­dence, which is em­phat­i­cal­ly strong. On­ly 2% of the crowd are less than some­what con­fi­dence, with three out of four run­ning the gamut of con­fi­dent to ex­treme­ly con­fi­dence.

We have 57% rat­ing the flow of in­vest­ments from VCs as ‘good.’

“The cap­i­tal is there from spe­cial­ists for the right com­pa­nies.”

“If you have a great team and a good sto­ry, you can get fund­ed.”

But not every­one is hap­py about their ac­cess to cap­i­tal these days.

“I am con­tin­u­al­ly per­plexed by the de­sire to fund “the dream” ver­sus val­i­dat­ed, re­al drugs. I wish there was more in­ter­est in re­al biotech com­pa­nies that have rev­enues and de­liv­er strong cash flows.”

IPOs are off to a so-so start af­ter a weak 2016, so it’s not too sur­pris­ing to see ex­pec­ta­tions are lim­it­ed for the rest of the year. Forty-two per­cent ranked the IPO sec­tor as fair, with 27% fair, 17% good and 14% poor. No one thought it was ex­cel­lent.

About half thought that the IPO mar­ket will stay this way for the rest of the year, with the “bet­ter” and “worse” group split 29% to 19%.


Hir­ing

Close to 4 out of 5 of these ex­ecs work in or with com­pa­nies that are hir­ing in the first quar­ter, al­so re­flect­ing a strong up­beat tem­po in terms of ex­pand­ing em­ploy­ment, which we al­so saw last fall in our first sur­vey. 86% are hir­ing this year. No one plans to re­duce staff. The biggest prob­lem cit­ed: Find­ing the right peo­ple can be dif­fi­cult.

“We’ll hire ag­gres­sive­ly again this year.”

“Job mar­ket re­mains very hot. Lots of com­pe­ti­tion to ac­cess the best tal­ent.”

“We’re hir­ing ag­gres­sive­ly but good can­di­dates are hard to find,” says Yu­val Co­hen, CEO of Cor­bus Phar­ma­ceu­ti­cals.”


Biotech val­u­a­tions: Fair to good

The pace on deals and buy­outs has start­ed off with some siz­able num­bers in biotech, but our E100 ex­ecs weren’t feel­ing gid­dy about any of it.

57% of these ex­ecs found li­cens­ing deals were be­ing done for av­er­age amounts, 37% said they were high and on­ly 5% thought of them as low. There was a split on M&A, though, with 47% rank­ing val­u­a­tions at av­er­age and 43% call­ing them out as high. That cold be a sell­ers per­spec­tive, though, as Big Phar­ma buy­ers have been say­ing for sev­er­al years now that val­u­a­tions have been run­ning ex­treme­ly high, in their view.


So where do we go from here?

“Let’s keep our eye on the prize: mak­ing im­por­tant new ther­a­peu­tics that ad­dress hu­man needs. Let us em­brace val­ue-based pric­ing. Let us shun var­i­ous his­tor­i­cal in­dus­try prac­tice to un­rea­son­ably ex­tend patent mo­nop­oly. Let us aban­don un­jus­ti­fied year-over-year cost in­creas­es in the ab­sence of proven ad­di­tion­al pa­tient ben­e­fit or con­ve­nience.”

“A good year for biotech in 2017. Too many ex­cel­lent tech­nolo­gies and in­no­va­tion . They all will find homes!”

We end with an anony­mous com­pli­ment:

“Well done, John and col­leagues. End­points is a re­fresh­ing new source for biotech- and phar­ma-re­lat­ed news and views.”

It was just 1 out of 98, but we see a trend de­vel­op­ing.

Do you have an idea for our next sur­vey? Drop me a line at john@end­pointsnews.com

  • Here’s a list of all par­tic­i­pat­ing End­points 100 ex­ec­u­tives
    Jef­frey Al­bers Blue­print Med­i­cines
    Alan Auer­bach Puma
    Stephane Ban­cel Mod­er­na
    Chuck Baum Mi­rati Ther­a­peu­tics
    John Bea­dle PsiOxus
    Kees Been Lyso­so­mal Ther­a­peu­tics
    Arie Bellde­grun Kite Phar­ma
    Nes­san Berming­ham In­tel­lia Ther­a­puet­ics
    Jean-Jacques Bi­en­aimé Bio­Marin Phar­ma­ceu­ti­cal
    Kate Bing­ham SV Life Sci­ences
    Detlev Bin­iszkiewicz Sur­face On­col­o­gy
    Kevin Bit­ter­man Po­laris Part­ners
    Robert Blum Cy­to­ki­net­ics, Inc.
    Bruce Booth At­las Ven­ture
    Ed­uar­do Bra­vo Tigenix, SAU
    Wern­er Cautreels Se­lec­ta
    Chip Clark Geno­cea Bio­sciences
    Robert Cof­fin Replimune
    Ron Co­hen Acor­da
    Yu­val Co­hen Cor­bus Phar­ma
    Robert Con­nel­ly Ax­cel­la (Pronu­tria)
    Bernard Coulie Pli­ant Ther­a­peu­tics
    John Crow­ley Am­i­cus
    David de Graaf Syn­tim­mune
    Kim Drap­kin Jounce Ther­a­peu­tics
    Cameron Dur­rant Kalo­Bios
    Glyn Ed­wards Sum­mit Ther­a­peu­tics plc
    Eliot Forster Im­muno­core
    Tas­sos Gi­anakakos MyoKar­dia
    David Giljo­hann Ex­i­cure
    Robert Gould Ful­crum Ther­a­peu­tics
    Max­ine Gowen Treve­na
    Mike Grey Am­plyx
    Geral­dine Hamil­ton Em­u­late
    John Hau­rum F-star
    Rachel Hau­r­witz Cari­bou
    Pe­ter Hecht Iron­wood
    Mary Lynne Hed­ley Tesaro
    Olav Helle­bø ReNeu­ron Group plc
    Rus­sell Hern­don Hy­dra Bio­sciences
    Rich Hey­man Hey­man Biotech
    Na­tal­ie Holles Au­dentes Ther­a­peu­tics, Inc.
    Steve Holtz­man Deci­bel Ther­a­peu­tics
    Hervé Hop­penot In­cyte
    An­nal­isa Jenk­ins Di­men­sion Ther­a­peu­tics
    Jeff Jonker NGM Bio
    Kevin Ju­dice DiCE Mol­e­cules
    Rachel King Gly­comimet­ics
    Gene Kin­ney Prothena
    Art Krieg Check­mate Phar­ma­ceu­ti­cals
    Je­re­my Levin Ovid Ther­a­peu­tics
    Howard Liang BeiGene
    Jay Lichter Aval­on Ven­tures
    John Maraganore Al­ny­lam
    Alex­ey Mar­golin Al­lena Phar­ma­ceu­ti­cals
    Tim Mayleben Es­pe­ri­on
    Sean Mc­Carthy Cy­tomX Ther­a­peu­tics
    David Mott NEA
    Lon­nie Moul­der Tesaro
    Glenn Ned­win Sec­ond Genome
    Don Nichol­son Nim­bus Ther­a­peu­tics
    Hugh O’Dowd Neon Ther­a­peu­tics
    Bernat Olle Vedan­ta
    Rick Orr Ad­ynxx
    Ju­lia Owens Mil­len­do
    An­toine Pa­piernik Sofinno­va
    Pier­lui­gi Parac­chi GENEN­TA Sci­ence
    Alexan­der Pas­teur F-Prime Cap­i­tal Part­ners
    Joe Payne Arc­turus Ther­a­peu­tics
    Michael Pelli­ni Foun­da­tion Med­i­cine
    An­drea Pfeifer AC Im­mune
    An­drew Phillips C4 Ther­a­peu­tics
    Richard Pops Alk­er­mes
    An­na Pro­topa­pas Mer­sana Ther­a­peu­tics
    Lau­rence Reid Warp Dri­ve Bio
    Nor­bert Riedel Aptinyx
    Adam Rosen­berg Rodin Ther­a­peu­tics
    Gregg San­do Cell Med­ica
    David Schenkein Agios
    Denise Scots-Knight Mereo Bio­phar­ma
    Paul Sekhri Lyc­era Corp.
    Tito Ser­afi­ni Atre­ca
    Ar­mon Sharei SQZ Ther­a­peu­tics
    Lau­ra Shawver Cleave Bio
    Clay Sie­gall Seat­tle Ge­net­ics
    Nan­cy Si­mon­ian Sy­ros Phar­ma­ceu­ti­cals
    Harpreet Singh Im­mat­ics US
    Sander Slootweg For­bion Cap­i­tal Part­ners
    Jeff Stein Cidara
    Carmine Sten­gone Ave­las Bio­sciences, Inc.
    Niclas Stiern­holm Tril­li­um Ther­a­peu­tics
    Clif­ford Stocks On­coRe­sponse
    Hamza Suria Anap­tys­Bio
    Mary Szela Aege­ri­on Phar­ma­ceu­ti­cals
    Nan­cy Thorn­ber­ry Kally­ope
    Praveen Tipir­neni Mor­phic Ther­a­peu­tic
    He­len Tor­ley Halozyme
    Dou­glas Tre­co Ra Phar­ma­ceu­ti­cals
    Steve Tre­gay For­ma Ther­a­peu­tics
    Tim Van Hauw­er­meiren Ar­genx
    Mark Vel­le­ca G1 Ther­a­peu­tics
    Greg Ver­dine Fog Phar­ma
    George Vla­suk Nav­i­tor Phar­ma­ceu­ti­cals, Inc.
    Robert Ward Ra­dius
    Ryan Watts De­nali
    Mal­colm Weir Hep­tares
    Mar­tin Welschof Op­sona Ther­a­peu­tics Ltd
    Doug Williams Co­di­ak
    Troy Wil­son Ku­ra On­col­o­gy
    Steve Yang WuXi AppTec
Brian Kaspar. AveXis via Twitter

AveX­is sci­en­tif­ic founder fires back at No­var­tis CEO Vas Narasimhan, 'cat­e­gor­i­cal­ly de­nies any wrong­do­ing'

Brian Kaspar’s head was among the first to roll at Novartis after company execs became aware of the fact that manipulated data had been included in its application for Zolgensma, now the world’s most expensive therapy.

But in his first public response, the scientific founder at AveXis — acquired by Novartis for $8.7 billion — is firing back. And he says that not only was he not involved in any wrongdoing, he’s ready to defend his name as needed.

I reached out to Brian Kaspar after Novartis put out word that he and his brother Allen had been axed in mid-May, two months after the company became aware of the allegations related to manipulated data. His response came back through his attorneys.

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UP­DAT­ED: An em­bold­ened As­traZeneca splurges $95M on a pri­or­i­ty re­view vouch­er. Where do they need the FDA to hus­tle up?

AstraZeneca is in a hurry.

We learned this morning that the pharma giant — not known as a big spender, until recently — forked over $95 million to get its hands on a priority review voucher from Sobi, otherwise known as Swedish Orphan Biovitrum.

That marks another step down on price for a PRV, which allows the holder to slash 4 months off of any FDA review time.

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Martin Shkreli [via Getty]

Pris­on­er #87850-053 does not get to add drug de­vel­op­er to his list of cred­its

Just days after Retrophin shed its last ties to founder Martin Shkreli, the biotech is reporting that the lead drug he co-invented flopped in a pivotal trial. Fosmetpantotenate flunked both the primary and key secondary endpoints in a placebo-controlled trial for a rare disease called pantothenate kinase-associated neurodegeneration, or PKAN.

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We­bi­nar: Re­al World End­points — the brave new world com­ing in build­ing fran­chise ther­a­pies

Several biopharma companies have been working on expanding drug labels through the use of real world endpoints, combing through the data to find evidence of a drug’s efficacy for particular indications. But we’ve just begun. Real World Evidence is becoming an important part of every clinical development plan, in the soup-through-nuts approach used in building franchises.

I’ve recruited a panel of 3 top experts in the field — the first in a series of premium webinars — to look at the practical realities governing what can be done today, and where this is headed over the next few years, at the prodding of the FDA.

ZHEN SU — Merck Serono’s Senior Vice President and Global Head of Oncology
ELLIOTT LEVY — Amgen’s Senior Vice President of Global Development
CHRIS BOSHOFF — Pfizer Oncology’s Chief Development Officer

A premium subscription to Endpoints News is required to attend this webinar. Please upgrade to either an Insider or Enterprise plan for access. Already have Endpoints Premium? Please sign-in below. You can contact our Subscriptions team at help@endpointsnews.com with any issues.

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Am­gen, Al­ler­gan biosim­i­lar of Roche's block­buster Rit­ux­an clears an­oth­er US piv­otal study 

Novartis $NVS may have given up, but Amgen $AMGN and Allergan $AGN are plowing ahead with their knockoff of Roche’s blockbuster biologic Rituxan in the United States.

Their copycat, ABP 798, was found to have a clinically equivalent impact as Rituxan — meeting the main goal of the study involving CD20-positive B-cell non-Hodgkin’s lymphoma patients. This is the second trial supporting the profile of the biosimilar. In January, it came through with positive PK results in patients with rheumatoid arthritis.

BeiGene and Mus­tang nail down spe­cial FDA sta­tus for top drugs; Roche bags added cov­er­age for Hem­li­bra

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Trump ad­min­is­tra­tion re­vives bid to get drug list prices on TV ads

The Trump administration is not giving up just yet. On Wednesday, the HHS filed an appeal against a judge’s decision in July to overturn a ruling obligating drug manufacturers to disclose the list price of their therapies in television adverts — hours before it was stipulated to go into effect.

In May, the HHS published a final ruling requiring drugmakers to divulge the wholesale acquisition cost— of a 30-day supply of the drug — in tv ads in a bid to enhance price transparency in the United States. The pharmaceutical industry has vehemently opposed the rule, asserting that list prices are not what a typical patient in the United States pays for treatment — that number is typically determined by the type of (or lack thereof) insurance coverage, deductibles and out-of-pocket costs. Although there is truth to that claim, the move was considered symbolic in the Trump administration’s healthcare agenda to hold drugmakers accountable in a climate where skyrocketing drug prices have incensed Americans on both sides of the aisle.

Ver­sant-backed Chi­nook gets a $65M launch round for its dis­cov­ery quest in a resur­gent kid­ney field

Versant is once again stepping off the beaten track in biotech to see if they can blaze a trail of their own in a field that has looked too thorny to many investors for years.

The venture group and their partners at Apple Tree are bringing their latest creation out of stealth mode today. Born in Versant’s Inception Sciences’ Chinook Therapeutics is betting that its preclinical take on kidney disease can get an early lead among the companies starting up in the field.

Sir An­drew Dil­lon, NICE's first — and on­ly — chief ex­ec­u­tive to step down next year

Using a laptop borrowed from his former employer, South London’s St George’s Hospital, Sir Andrew Dillon set about establishing NICE — launched by the then health secretary Frank Dobson — in 1999.  On Thursday, the UK cost-effectiveness watchdog said its first and only chief executive — Dillon — is stepping down in March 2020.

Back in the day, decisions about which drugs and interventions were funded by the National Health Service (NHS) were made at the local level, but this ‘postcode prescribing’ system was fraught with skewed healthcare deployment making the structure unsustainable. A national system was deemed necessary — and NICE was formed to bridge that gap.