24 August 2010


The price of life?

The National Institute for Health and Clinical Excellence (NICE), charged to determine whether drugs are good value for money for the NHS, has decided that the anti-bowel cancer drug avastin, also known as bevacizumab, is not worth the average cost of £21,000 per patient for an average extension of life expectancy of only six weeks. It is used only in advanced cases.

The campaign group Bowel Cancer UK has protested against the decision, arguing that the 6,500 sufferers each year have a right to any medication that might extend their lives.

However, I have to agree with NICE: £21,000 for six weeks extra life is not good value for money for the taxpayer. On the figures quoted it appears the extra cost to the taxpayer would be £136m per year.

I certainly would not expect that sort of public expenditure to keep me alive for an extra six weeks and if ever I am in the unfortunate position of suffering from bowel cancer I will refuse the drug if offered on the NHS. I or my relatives might have special reasons to want those extra weeks of life for me and might be prepared to find the money by some means but I would not expect the taxpayer to stomp it up.

The decision is riddled with questions of relativity. Suppose the equation were £100,000 for just one extra day of life? How many would argue for it then? Issues of quality of life are also relevant and no doubt NICE takes those into account too in arriving at its decisions.

This is not the sort of decision that can be taken on the basis of a principle – it has to be on the basis of common sense.

I believe there are a number of drugs that have not made it on to NICE’s list for the same reason. If all were approved on principle then NHS costs would rise significantly and drugs companies would be given licence to manufacture all sorts of exotic and expensive drugs in the sure knowledge that the NHS would have to cover the cost. Their profits would be guaranteed on the back of a rising tax bill for working people.

You are entitled to ask where I would draw the line and for the sake of argument I propose that drugs should only be approved if for a cost equivalent to the national average annual wage (circa £26,000) an extension of life of 12 months could be anticipated. No, there’s no connection, it’s just an intuitive guide to reasonableness.

Anyone contributing is, I think, obliged to state where they would draw the line.


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Another approach to this question is to ask for whom you would personally pay £21000 to extend their life by 6 weeks. If you would part with that amount (assuming you are not rich) then it would be understandable for you to expect the NHS to do the same. If not......
There are three people for whom I would DEFINITELY pay the £21000: my two daughters, and the scientist within six weeks of a breakthrough in concocting a cheap drug which would cure bowel cancer or extend the lives of sufferers by many years.

There are two people for whom I would definitely NOT pay the £21000: myself and my husband.

For all others, like a good Humanist, I would consider their cases on their individual merits. Maybe the NHS should allow clinicians to do the same.
There's a need for all to recognise that the NHS does not have its own money tree. What it spends, we, the taxpayer, pays. If you are not a taxpayer, so what? Well, it does matter because if the NHS is seen to be spending public money recklessly it will bring the whole organisation into disrepute and make it that much easier for the ideological enemies of state healthcare to win an election on the back of a policy of dismantling it.

Supporters of the NHS should be the keenest to see that it spends money wisely and gets good value for money. This is not a 'moral' or human rights question, it is a simple economic one that shades into politics.

The problem with saying that decisions should be left to clinicians on the basis of individual merit is that it places too much responsibility on them and puts them in the firing line. Some would say it puts them in the position of God, but obviously, on an atheist blog, you would not expect to see that argument!

What would you do if you were a clinician who had discretion? You would give the drug to everybody, of course, to avoid all the challenges that would follow even the most sensible of discriminations. Then it would be impossible to control the budget and drugs companies would be encouraged to manufacture all sorts of exotic drugs at exorbitant prices that they knew would find a ready market in the NHS.

Either the mildly rough justice of a body like NICE, deciding which drugs provide reasonable value for public NHS money, or some other form of central rationing - eg. nobody over 50 to be given the drug, or smokers, or clinically obese people, etc. etc., could take the pressure of both the budgets and the clinicians.

Well firstly I'd like to say I'm a new reader of this blog, and I look forward to many articles that prompt me to think about issues that I would perhaps otherwise not have been exposed to.

It seems to me that the question as posed - what price/value can you place on life, to paraphrase - is the wrong question. Sure, if an intervention, in this case a drug, actually cost £21000 to manufacture and distribute then I think this discussion would be worth having.

But it doesn't cost that much does it? It only costs that much because that's what the pharmaceutical company decides to charge for it. And they can pretty much charge what they like.

For me the real question is should we allow that? You are right that we have to be good stewards of public money. But can it be right to deny interventions to people because the pharmaceutical business wants to maintain it's status quo as "the most profitable industry in the US"?
It seems we all despise the pharmaceutical companies for making big profits out of drug manufacture and selling them to our NHS at exorbitant prices. OK, OK. Let's put that on one side. Is that possible? No doubt there will be many who will object to dealing in hypotheticals but I've always found those objections to be lame excuses, cop outs, to avoid dealing rationally and realistically with very real issues. Similar issues are being dealt with in a thousand ways each day of the week. We individually make decisions about our own and our children's welfare based on how much it will cost. A few years ago I was diagnosed with a heart problem. I was told that the waiting time for a simple operation, that might fix it, on the NHS was three months. I rang the local BUPA hospital and found they could do it within a week for a charge of around £650. I had the cash but decided against going with BUPA because there was no guarantee it would work and I might then be facing another £650 to have a second go or to attempt something else. I put a price on my health.

Similarly, we could as a nation put an end to almost all road traffic accident deaths by banning motor vehicles. Why don't we do it? Because the cost in terms of lost economic activity and mass poverty that would follow would be unbearable.

So, there is currently a frequent and well known practice of making decisions about human welfare based on cost.

Just assume for a moment that we live in a non-capitalist democratic world where we are constantly faced with decisions about the application of scarce resources to meeting human needs. Let us assume, further, that there is a rare fatal physiological disorder that the state medical researchers believe can be delayed in its fatal effect by a period of one week if a new machine is built. The machine will cost £10m to build. It will extend the lives of 5 people each year by one week. The machine's working life is estimated at 5 years. So, each extra week of life for the five victims annually will cost £400,000 of taxpayers' money.

Is it worth it?

It's a simple enough question.

Harry, I cannot let you get away with that comment on motor vehicles. Whilst banning them overnight with no warning would of course cause chaos, phasing them out over time is a sensible and entirely viable way to eliminate road traffic accident deaths. It is only politics, culture and vested interests that prevent it.
Well, and civilisation as we know it.
Harry, the list of advantages of a car-free society in social, economic and health terms is well-worn and well-documented, even if you personally are not familiar with it. I do not think it is a good use of my scarce and valuable time to relate them here. If any readers of this blog are interested, it should not take long to unearth plenty of relevant information on the web.
I'm going to support the pharmaceutical companies here. Of course, I don't think they are faultless, far from it, and there is certainly as much corruption within big pharma as anywhere. However, the cost of producing a drug, one that MUST work beyond placebo (in order to qualify as a medicine) and which "does no harm" (within limits!) is colossal and, of course, we as users, only see the "successes". Many drugs, costing millions to research, are found to be wanting very late in their development and must be scrapped. The R & D money, sometimes running to hundreds of millions of pounds, is lost. In order to pay for the ones that don't work - but which might have done - the cost of the successes are inflated. That is the same with any industry. The only way around that is to change the hoops that the companies have to jump through and risk dangerous (or useless) drugs being marketed. The wonderful advances that we benefit from come with a price, the alternative is to risk losing some of the pharmaceutical companies that may otherwise be the ones that develop the cancer-treating drugs that we all hope for.

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