I like to think that one of the reasons we love the NHS is that the general population in the UK has a sense of fairness that is largely independent of where individuals stand on the political spectrum. We may argue about the finer details but the overwhelming majority of us agree that a healthcare system that is free at the point of need is fair.
Where there are arguments about fairness in the NHS they tend to focus around who ‘deserves’ care, and there are a number of easy targets. Common focuses of frustration and disagreement are ‘health tourism’ – non-UK citizens receiving free care; the ‘undeserving’ sick – people whose lifestyle choices may have caused their ill health; and the ‘frivolous’ patients – those who want treatment to enhance their life rather than cure ill health.
While there are many arguments about whether it is fair that one group or another should receive free healthcare, in another area there seems to be an overwhelming consensus that fairness means ever-greater funding. Many new drugs coming onto the market that advance treatments in life-threatening illness are eye-wateringly expensive. Yet when NICE says it can’t justify the expense for the benefits patients will receive, it is regularly vilified as denying hope to dying people.
As we read the undeniably sad stories of individuals being denied a drug that may give them an extra two months of life, of course we sympathise – and empathise. We want them to have the drug, and the chance of that extra couple of months. But the drug will be paid for from the finite resources of the NHS, so it will mean denying other people other treatments. The reason we don’t get as agitated about those people is that we don’t have their story, or a picture of them because they aren’t an identified individual. They are a group affected by a changed target or policy, and rather than dying earlier, they may just have to put up with pain and immobility for a while longer, a cheaper and less effective treatment, fewer community nurse visitis or fewer sessions of a much-needed therapy.
I wouldn’t like the job of deciding where the fairness line should be drawn, and I am certainly not suggesting that funding for expensive new drugs should be routinely refused. But a research report from the University of York recently suggested that, far from being miserly when it comes to approving expensive new drugs, NICE is actually too generous in the amount of money it recommends spending per quality-adjusted life year.
The report recommends that spending decisions look not only at the QALYs that may be gained by individual patients who receive expensive new drugs, but also at the QALYs likely to be lost elsewhere in the system in additional deaths, life years lost and poorer quality of life for the ‘unknown’ people. That sounds fair to me – what do you think?