NICE, politics and puppetry
There has been a call for NICE to see cancer drugs differently from other treatments. Has NICE really got it's sums wrong?
The payor and the beneficiary have been separated by the existence of a political promise that the NHS will deliver treatment to the patient free at the point of delivery.
Assume a treatment that carries proven clinical benefit. From the perspective of a patient a treatment is free when they do not need to pay for themselves directly. But almost any such free treatment, however small the potential net benefit, which gives a potential for an increased chance of survival almost inevitably carries utility. Cost free utility carries value and is the driver for infinite demand.
NICE is the politicians tool to address the demand side of the supply-demand imbalance for healthcare within the NHS. NICE answers the question whether the drugs are value for money from the perspective of a fee-payer with a finite resource who is seeking to discharge a duty to deliver care. NICE possesses a legal power permitting it to instruct the NHS in general questions of resource deployment.
This dichtomy of perspectives upon the utility of a given treatment lies the heart of the argument. Therefore in order to avoid confusion we need to change the language of the debate. This means moving the language away from ambiguous talk of "treatments that are value for money" and "cost-effectiveness". The core argument is whether and how to "ration treatments".
From the position of NICE the key concern is to maximise outcomes per unit resource deployed. Often questions of "opportunity cost" arise in this context.
From the perspective of the patient the issue is about the value of the politicians' promise that the patient has the "right to healthcare free at the point of delivery". Presently this right seems to be worth about £30,000 per QUALY.
From my perspective, and it seems that of some of the cancer specialists, the words "right to healthcare free at the point of delivery" do not simply or completely equate to £30,000 per QUALY. This view is, however, not shared by NICE.
To counter NICE's view one might argue that:
The payor and the beneficiary have been separated by the existence of a political promise that the NHS will deliver treatment to the patient free at the point of delivery.
Assume a treatment that carries proven clinical benefit. From the perspective of a patient a treatment is free when they do not need to pay for themselves directly. But almost any such free treatment, however small the potential net benefit, which gives a potential for an increased chance of survival almost inevitably carries utility. Cost free utility carries value and is the driver for infinite demand.
NICE is the politicians tool to address the demand side of the supply-demand imbalance for healthcare within the NHS. NICE answers the question whether the drugs are value for money from the perspective of a fee-payer with a finite resource who is seeking to discharge a duty to deliver care. NICE possesses a legal power permitting it to instruct the NHS in general questions of resource deployment.
This dichtomy of perspectives upon the utility of a given treatment lies the heart of the argument. Therefore in order to avoid confusion we need to change the language of the debate. This means moving the language away from ambiguous talk of "treatments that are value for money" and "cost-effectiveness". The core argument is whether and how to "ration treatments".
From the position of NICE the key concern is to maximise outcomes per unit resource deployed. Often questions of "opportunity cost" arise in this context.
From the perspective of the patient the issue is about the value of the politicians' promise that the patient has the "right to healthcare free at the point of delivery". Presently this right seems to be worth about £30,000 per QUALY.
From my perspective, and it seems that of some of the cancer specialists, the words "right to healthcare free at the point of delivery" do not simply or completely equate to £30,000 per QUALY. This view is, however, not shared by NICE.
To counter NICE's view one might argue that:
- cancer is a disease that makes it subject to different rules; or
- that you object to the way NICE does its sums; or
- that you objects to the fact that NICE has to do any sums at all.
The debate then rests in a mixture of ethics and politics. If you are going to take a position then it is worth being clear where you stand in relation to each.
If you accept (1) above then you could argue that NICE can do what it likes but it should not consider cancer treatments - i.e. NICE should be rationed. This requires one of 2 arguments :
(i) the old argument that life span improvements cannot be directly equated with mere increases in quality of life; or
(ii) that there is something intangible about a patient's experience of the disease of cancer that makes it worth the additional resource. The latter is an emotionally charged argument but not an untenable one.
Arguing about (2) is relatively fruitless. The court cases show that NICE has the power to make decisons that ration care provided it keeps its processes transparent and just. NICE is after all just a limb of Government albeit a QUANGO.
Arguing about (3) means focusing upon the politicians - we have seen the tax rises supposedly used to pay for the NHS but now the money has run out again. Crucially the politicians can easily use NICE as the whipping boy for decisons that in reality fall to them.
Why should politicians make such decisions rather than NICE? Firstly because NICE is accountable to the politicians. Secondly because the politicians are ultimately responsible for sanctioning the decisions made by NICE. Thirdly becasue the polticians, not NICE, are directly accountable to the people who face cancer and are receiving less than the best available treatment.
This debate is not about NICE's sums. It is about rationing and healthcare. Why should NICE make decisions that have political and ethical complexity and impact upon the lives of people to whom NICE is not directly accountable?
What seems to be missing here is the moment where the politicians admit that there is rationing in the NHS and then there is an open political debate about what to do about this fact. Beating NICE with a stick is at best a distraction. The public, the medical profession and the patients must not let the politicians escape from the admission they must make and the debate that needs to be had.
If you accept (1) above then you could argue that NICE can do what it likes but it should not consider cancer treatments - i.e. NICE should be rationed. This requires one of 2 arguments :
(i) the old argument that life span improvements cannot be directly equated with mere increases in quality of life; or
(ii) that there is something intangible about a patient's experience of the disease of cancer that makes it worth the additional resource. The latter is an emotionally charged argument but not an untenable one.
Arguing about (2) is relatively fruitless. The court cases show that NICE has the power to make decisons that ration care provided it keeps its processes transparent and just. NICE is after all just a limb of Government albeit a QUANGO.
Arguing about (3) means focusing upon the politicians - we have seen the tax rises supposedly used to pay for the NHS but now the money has run out again. Crucially the politicians can easily use NICE as the whipping boy for decisons that in reality fall to them.
Why should politicians make such decisions rather than NICE? Firstly because NICE is accountable to the politicians. Secondly because the politicians are ultimately responsible for sanctioning the decisions made by NICE. Thirdly becasue the polticians, not NICE, are directly accountable to the people who face cancer and are receiving less than the best available treatment.
This debate is not about NICE's sums. It is about rationing and healthcare. Why should NICE make decisions that have political and ethical complexity and impact upon the lives of people to whom NICE is not directly accountable?
What seems to be missing here is the moment where the politicians admit that there is rationing in the NHS and then there is an open political debate about what to do about this fact. Beating NICE with a stick is at best a distraction. The public, the medical profession and the patients must not let the politicians escape from the admission they must make and the debate that needs to be had.
(c) R Mohindra 2008
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