I was going to blog about the Drobo. I in fact wrote the blog last night to publish today. But this mornings headline in the metro annoyed me so that will have to wait till Monday.
"Cancer Patient saved by judge" the Metro headline reads. The article then goes on to detail how Colin Ross sued his local NHS to put him on the drug and won, because the judge ruled that it being refused because it was not cost effective was unlawful.
Are you fricking crazy?
The case is likely to increase pressure on NHS trusts to fund cancer drugs, even before their cost effectiveness has been assessed. - The Independant
Now I get Colin Ross, no one wants to die. I would do everything I could to get the drug (although curious to know the legal costs of the case). However I vehemently disagree with the judge and really hate the way the papers blow up these "treatment refused because not cost effect stories". They were all over the place about a year ago with this breast cancer treatment drug.
It simple maths. There is one pot of money and it can't treat everybody for everything. So what happens is the National Institute for Clinical Excellence (NICE) has to work out what's best for everyone.
So lets take two drugs. One cures cancer 10% of the time and costs £40k. One prevents heart disease 80% of the time and costs £4k. So for £400k you can save 1 cancer patient or prevent heart disease in 80 patients. Which drug are you going to recommend?
I understand people are uneasy with the idea that human live has value, and a specific monetary value. Sure it sucks. Sure we would like to treat everyone, all the time. But it's just simply not possible. One pot of money remember.
Now you might disagree with specific decisions or specific cases, but it's the way the press generally reflects NICE as evil, or bad, killing people. But for every treatment that someone gets, it's a treatment that someone else is not getting. And this never is reflected in the press. And even this postcode lottery, whilst their are obvious problems in the system that need to be worked on, some areas of the country might have different priorities to others. So it makes sense for different NHS trusts to allocate resources differently.
I would have titled that article "Non medical judge kills several people with ruling"
1. Andrew
Surprisingly, I find myself agreeing with you.
I agree that it is not a nice situation to be in, but if it was me fighting for payment of my treatment knowing there was a limited pot of cash, I would keep thinking of the 80 individuals who would not be getting their heart disease treatment. It would be impossible to picking from a list of 80 names yourself.
It would be interesting to know why he would get treatment in another post code though, another point brought up in the article.
2. Adrian
So I think their is validity in addressing how and why treatments are available in some areas and not others.
Either their is a proper reason for this and it needs to be communicated better, or their isn’t and the system needs to be fixed.
However regardless of that the press generally IMvHO does a terrible job of highlighting the fact that every time the press publicises and in some cases forces the NHS to use a drug the reality is somewhere else someone else it not getting treatment for something else.
The general write up is Villan = NICE Hero = Very photogenic blonde mother of X with breast cancer
This really annoys me. I will say some of the papers are worse than others on this.
3. Danzor
Wait, run me through this math again: One drug cures cancer 10% of the time and costs £40k. Another prevents heart disease 80% of the time and costs £4k. So for £400k you can save 1 cancer patient or prevent heart disease in 80 patients.
Why are you using 4k, 40k and 400k as benchmarks? Just use one figure as the benchmark- every time you multiply it for one set of figures, you’re throwing out the other set of figures. Assuming we’re talking about 100 people, 40k would save 10 people in the case of cancer, and 80 people in the case of heart disease. In no circumstances would 400k save 1 person vs. 80 people, given the figures you’ve described.
Not disagreeing with your point, mind you- just saying that it’s not well served by dodgy math.
4. Danzor
Okay I’ve just noticed that my OWN math is also dodgy. But that is only because you confused me with your math, which used different benchmarks. So while my solution is also wrong, it’s because you messed up the field with dodgy figures. Rewrite your statement using ONE financial benchmark, and it will all make sense.
5. Adrian
My maths is perfect dude. I’m not sure what you mean by 1 financial statement.
I’m comparing two meds of different costs and efficiencies.
MedX works 10% of the time at a cost of £40k per treatment MedY works 80% of the time at a cost of £4k per treatment
Hence if an NHS trust has a budget of £400k
MedX gives 10 treatments of which 1/10 works which means 1 person is cured. MedY gives 100 treatments of which 8/10 work which means 80 people are cured.
So if the trust bows to public pressure and gives the MedX then one person is cured, but 80 other people don’t get access to MedY.
Obviously I’ve really simplified things here, but I’m trying to explain why NICE needs to evaluate cost vs effectiveness. Obviously they also evaluate the type of drug (i.e. saves lives vs improves quality of life vs etc etc etc)
6. Marc
Firstly the case wasn’t about “treatment refused because not cost effect[ive]”, that was the reason and argument made by the Trust. It was about the interpretation of their policy.
The judge didn’t rule “that it being refused because it was not cost effective was unlawful”. He ruled that the reason not to fund based on materials such as their exception policy was unlawful. He did say the panel fell in error over the cost effectiveness of this particular drug.
The precedent from the case will not be that it is unlawful to refuse treatment based on cost effectiveness but for cases where there is policy ambiguity that allows cost effectiveness to be used as a means to arbitrarily deny treatment. It is a subtle difference I grant you but important nonetheless that should not open the flood gates.
If this was about insurance it would be akin to a policy that said if it’s an Act of God claim then we’ll decide to pay if it’s cost effective for us at the time that you make the claim. Either tell me you’re not or what the maximum payout is in the policy.
“National Institute for Clinical Excellence (NICE) has to work out what’s best for everyone”. In this case NICE haven’t even come into play yet nor was it relevant. They do make recommendations about whether drugs are cost effective but they are still in the appraisal phase for this particular drug. Although they will almost certainly say that the drug is too expensive; based on similarly priced treatments, that prolong life as opposed to curing the patient, that they have turned down.
Nevertheless despite your overall point having some validity, your example is contrived. If you do want to make the one pot argument then be inclusive of non-life threatening treatments and procedures as well as ancillary costs and inefficiencies.
For example, the National Audit Office has estimated that £200m a year could be saved on prescription drugs without affecting patient care. Further to that £100m of prescribed drugs are wasted or unused every year. Revlimid treatment costs £20k, which would be 10,000 multiple myeloma patients that could have their lives saved or extended per year using Revlimid. That doesn’t even include the savings with usage of generic drugs over branded drugs.
The number of new multiple myeloma cases in 2001 was 3145 and 2005 was 3,970. Multiple myeloma accounts for only 1% of all cancer cases but the point is made; save 4000 people and tell 3m people to go home and stop whinging rather than prescribing them drugs they don’t need and telling the 4000 that the treatment is not cost effective. Of course my argument is as oversimplified but not nearly as contrived as yours. Yes perhaps that money could be spent better elsewhere but don’t say that it’s a simple maths game of saving a certain amount of people over another set.
So to conclude, I do agree with your general point that the line has to be drawn somewhere however your argument has no relevance to this case and was just as fallacious as comments in the paper that state “The case is likely to increase pressure on NHS trusts to fund cancer drugs, even before their cost effectiveness has been assessed”. This case has merely set a precedent for case where policies discriminate unfairly. It does not open the door for the NHS to fund trial cancer drugs.
7. Marc
Your maths is correct and made perfect sense.
8. Andrew
Marc, a question….
“The precedent from the case will not be that it is unlawful to refuse treatment based on cost-effectiveness but for cases where there is policy ambiguity that allows cost-effectiveness to be used as a means to arbitrarily deny treatment.”
I thought that cost effectiveness was a defining criteria for which drugs (which I read as meaning a part of “treatment”) the NHS, and by extension PCT’s and secondary care trusts, pay for.
Is this not correct, as your statement would indicate that Trusts cannot use this lawfully as a reason to deny treatment?
If they cannot use this lawfully as a reason to deny treatment, does this note reduce the value of the National Institute of Clinical Excellence (to nothing).
I would also like to bring up another point - NICE implement a model based on Quality of Life Year which has a cost effectiveness threshold of between £20 and £30k a year I believe. It is NICE’s job to determine if a drug is above or below the treshold, however I understand this threshold has no basis in theory or evidence. Other treatmeants in other part of the patient journey may indeed be much more effective (perhaps goign to the gym, perhaps going on a diet).
9. Andrew
Apologies, of course NICE do a lot of things other than assessing the cost effectiveness of treatment, such as assessing health technologies and producing guidelines.
10. Adrian
@Marc
I disagree with the judges ruling. The trust said that they didn’t think the drug would be cost effective. They are allowed to make that decision till NICE rules on it
Their lawyers argued that nearby PCTs allow the drug. That doesn’t mean nearby PCTs have made the right decision. Either way each PCT needs to make their own decisions till NICE rules.
The mechanism of “exceptional” or “unique” might be a faulty way of dealing with it, but I don’t think it really is what this is about. And this really is about who do you provide what med’s to and what is the most effective. Which is why we have NICE. It appears till NICE rules the PCT’s need to make their own decisions. Biut the decision is still the same evaluation as what NICE does.
My example is contrived. Deliberately. To make the concept simple to understand. The reality is obviously far more complex. The news tends to not point out either. Choosing rather to look like people are just refusing treatment on a whim. This is not the case and my example is trying to simplify and highlight why this is not the case in an easy to understand model.
Fat in the system is a separate argument. Regardless of what NICE recommend, trusts and medical practices should be doing their utmost to reduce waste and trim fat and prescribe correctly. This is unrelated to the recommendation of a medicine, and related to making sure money in the pot doesn’t get wasted.
People should not be prescribed drugs they don’t need. I totally agree. However this is not what NICE does and not what NICE recommends. NICe (ASFAIK) works out weather a drug is cost effective for generally use or not. Not how much wastage is in the system.
People just don’t like “cost effective” when applied to peoples lives.
My argument was not drawn from the quote I quoted. I just used that to highlight a point. This is been something that has been bothering me since the breast cancer drug case with Herceptin recently which was similar and NICE was over ruled because of public pressure.
11. Andrew
For what it’s worth, my sources tell me the value of an average UK life to the NHS is £745,000.
This is calculated as £30,000 per QALY, the threshold that NICE uses [1], multiplied by 63.2 healthy life years at birth in the UK [2] (which one assumes is more or less the same as a QALY) multiplied by a discounting factor of 0.393 to allow for economic discounting at approximately the current HM Treasury rate [3] (=1.03^(-63.2/2)).
12. cian
All drugs should be based on Sex Panther statistics.
“60% of the time, it works all the time.”
13. Marc (aka The Commentator Formerly Known as Chopper)
Sorry I haven’t made my points clear. I have a tendency to waffle. I was not arguing that PCT should not be able to determine the cost-effectiveness of drugs against the recommendation or as yet to be appraised by NICE.
My points were:
That the judgement, irrelevant of the initial intentions of the pursuant, or the actual basis for refusal of the defendants ended up based around, for want of a clearer word, a loophole in the ambiguity of their policy. The effect of which should be to remove these ambiguities rather than open other claims based on cost effectiveness. As such the judge in my absolutely unqualified opinion is not a “Non medical judge [who] kills several people with ruling”.
The exceptional funding is mostly subjective, by a panel at the PCT made up of clinical staff and lay people. And it’s varies across the PCTs. According to the Rare Cancer Forum survey there is a huge variation between PCTs’ approval rates, with 11 approving all and 3 approving none. I have no data on the correlation of finances of PCTs versus their approval rates. To say that the PCT was right or wrong or a non-medical judge was right or wrong doesn’t make sense. Without national guidelines these are just arbitrary decisions.
That your example while trying to illuminate us on the single pot was fallacious. Arguing that it was over saving one person with one disease over 10 with another is just not how it is. The determination should not be a lottery. It should take into account a variety of factors, including cost, health and clinical effectiveness as well as equity. There is always the possibility that the neighbouring PCT would have turned him down even though they had approved someone else for the same treatment. These things will be approved on a case by case basis but there has to be equality across the board.
In this case you are looking at possibly extending the man’s life from 2 months to 3 years at a cost of £20,000 for a 4 treatment course. Someone on dialysis would cost £30k a year. So the cost is certainly not an issue here. Now I can’t make a call on the health, cost or clinical effectiveness but cost doesn’t appear to be the issue.
Of course if I was Mr. Ross I would have probably just moved house to a PCT that had a higher approval rate.
14. Adrian
@Marc
Ok, you are right as respective to the judgement (it was a loop hole). However then the title “Cancer patient saved by judge” should have read “Cancer patient saved by legal loop hole”. A judge still made a decision that resulted in other treatments not being given to other people. The article didn’t make this clear at all and that’s what i was trying to highlight.
NICE is their to give the PCT guidance. Without NICE they have to make their decisions, but I suspect they are not arbitrary. They might be wrong, but they are based on data, previous experience (as they make more than one decision), and medical advisement. And of course these things will vary, but until NICE makes a ruling that’s going to be natural.
Of course when NICE does rule (say in the Herceptin case) and the public doesn’t like it, this gets overruled because people don’t like a cost valuation on life, or pretty blond women in the paper dying.
My argument over the single pot is trying to explain what NICE (and in this case the PCT) need to determine. It’s a simplified example to explain things. I did say the reality was for more complex. It’s trying to explain why effectiveness of treatment is important and why the factors of effectiveness and cost need to be taken into account. If you read Andrew’s comments he explain in a bit further detail how NICE evaluate stuff.
Of course it’s massively more complicated than my example. But the press never ever points out the basic fact that for everyone now getting Herceptin, somebody else is not getting some other treatment. That is what I was trying to show.
In Mr Ross’s case I would have moved or sued or done whatever was easiest to not die. I think moving would have been easier, because a judge could always rule against you.
15. Andrew
Couple of interesting articles in The Independent today on drug pricing, focusing on pharma co.s funding health charities who then lobby NICE….
http://www.independent.co.uk/life-style/health-and-wellbeing/health-news/analysis-are-patient-protests-being-manipulated-947317.html