Should the NHS cure or care? Is the National Institute for Health and Care Excellence, NICE or nasty?
Edmund Stubbs, 19 February 2015
Today researchers based in York have made an attempt to bring the NHS’s astronomical spending on drugs, especially those for cancer treatment, back down to earth. They claim that the high cost of almost all drugs approved by the National Institute for Health and Care Excellence (NICE) effectively harms patients by necessitating budget cuts elsewhere in the system.
How is this possible ? Essentially NICE evaluates the effectiveness of new drugs according to a system of ‘Quality Adjusted Life Years’ (QALYs); here one QALY is a year of life spent in perfect health, half a year spent in perfect health would be represented by 0.5 QALYs; and a year spend with a slight disability will count as slightly less than one QALY. For example, a year of suffering from moderate back pain might be scored at 0.95 QALYs while a year spent in hospital, in a critical condition might only score, say 0.2 QALYs.
These values are ascertained by questioning those suffering from the diseases and disabilities, they involve ‘healthy time’ trade-off calculations and hypothetical ‘gambling’ between the clinical risks run in attaining perfect health against those of enduring current affliction. Suffering is also assessed according to a numerical scale. New drugs can then be rated according to their effectiveness per QALY, with NICE presently often approving drugs that cost up to between £20,000 to £30,000 per QALY.
The York researchers claim that any approved drug costing above £13,000 per QALY might do more harm to the rest of patients in our health system than it might do good to those that benefit from the new drug. Thus, far from not spending enough on new pharmaceuticals, we are in fact spending too much.
When confronted with this ethical conundrum we must first remember the founding principles of the NHS. In essence, the NHS is an insurance system, pooling the risks of the entire population in order to minimise that to any individual confronted by a costly to treat and perhaps life threatening disease.
This pooling of risk may have been more simple in the early years of the NHS when communicable diseases were much more common. As a generalisation, people became ill, and either recovered after treatment or died. Now however, chronic illness is much more common, people survive longer with their diseases and the NHS has consequently to cure and subsequently care for these individuals on a long term basis.
The role of the NHS is therefore gradually shifting from exclusively saving individuals from health crises (as rudimentary health care systems attempting universal cover are now starting to do in developing countries) to the implementation of disease management programmes and chronic symptom alleviation.
This is where the concept of QALYs can be seen as possessing strength or weakness. They aim to combine length of life with an assessment of possible quality of life in order to make tough decisions possible. Thus patients facing an imminent end to their lives are effectively grouped indifferently with those who are in no immediate danger of death but who need their chronic conditions to be well managed in order to live a comfortable and meaningful life.
Professor Karl Claxton’s team at York have done us the great service of informing us of the consequences (which politicians ignore for populist reasons) of undifferentiated drug expenditure, on the rest of our health service. Nevertheless, the debate as to whether NICE’s QALYS computations in fact lead us to spend unjustified amounts on pharmaceuticals is still very much open. We must take into account the NHS’s present and future roles as both a curer and carer rather than perhaps being forced to decide which of these roles takes priority.
Edmund Stubbs, Healthcare Researcher