Sick and Wrong

I think I should apply for a job as a Daily Mail writer. It seems so easy. In order to write a Daily Mail article one merely needs to follow this three step process:

1. Take a standard Daily Mail premise (i.e. “Asylum seekers are evil…)

2. Find a random statistic and throw it in.

3. Conclude that some part of the country in hideously broken.

This explains why the Daily Mail-o-matic is so astoundingly accurate.

So this story and editorial comment has a simple point to make: life-saving cancer drugs are being denied by NICE (National Institute for Health and Clinical Excellence), whilst at the same time the NHS wastes £21billion (yes billion) on ‘failed schemes to tackle inequality.’

The headlines are great aren’t they: Betrayal of 20,000 cancer patients… and NHS waste betrays our cancer patients.

I’m a huge fan of Warner Brother’s Looney Tunes Cartoons (Bugs Bunny, Daffy Duck, Road Runner etc.) and it’s a intriguing fact that they employed joke writers who got paid $50 for each gag that was then included in a cartoon. I’m beginning to wonder if the Mail employs headline writers on a similar basis; £1000 for ‘NHS Waste’ – £2000 for “cancer” etc. If so, they’re really earned their money. As usual, the article is almost entirely untrue. I think what depresses me most is the comments section of Mail articles. People actually believe this stuff. This is the main reason why I am very grateful to angrymob for allowing me to contribute articles. It’s extremely therapeutic to me to be able to respond – it is a shame that the angrymob readership is not as wide as the Wail, but it is a start. “You shall know the truth and the truth will set you free” as a wise man once said.

£21 Billion

I read this article because of the reporting on the workings of NICE but what really caught my eye was the £21billion claim. It’s classic Mail really; billions of pounds wasted on tackling inequality. Because we (Mail Readers) all know that tackling inequality is part of the evil-socialist-not-really-British-human-rights-nu-labor-agenda. It’s almost like subliminal messaging only with the subtlety of a bulldozer. The reason this line caught my eye so much is that there is no way it could possibly be true. And the writer must have know this – this can’t just be an error or a misunderstanding – it’s so off-the scale wrong that it’s obvious after about 2 seconds of thought.

Last week it emerged that £21billion – a fifth of the entire annual budget – was spent on failed schemes to tackle inequality.

It took a little bit of research to work out what on earth this referred to and having found the answer, I have to admit I am impressed by their creativity. This figure is derived from a National Audit Commission report entitled “Healthy Balance” which looked at public health spending in England. As an aside, this is the short summary of the report:

The health of people in England has improved over the past ten years. Life expectancy has increased, infant mortality has fallen. Government targets to cut death from heart disease and stroke by 2010 have already been met. But if the big picture is positive, stark problems remain. Inequalities in the health of people from certain areas and social backgrounds has stubbornly resisted improvement, and has even increased in some cases.

So, public health programs from the government have been very successful but health inequalities remain a challenge. This is how they get to say that schemes to tackle inequality have ‘failed.’ So what of this £21 billion spent – from the article is seems this is a specific budget on schemes to tackle inequality – bureaucracy and PR are the sorts of things this statement conjures in my mind, certainly no actual healthcare. The reason I knew this was a lie, is the simple fact that this is impossible – there is no way the NHS could spend a fifth of its budget this way – it’s just untenable and hence the writers must have know it was false. So I found the figure of £21 billion buried in the article. What it comes down to is this; The government provides funding for the NHS in England by providing funds to PCT (Primary Care Trusts) who then control the money and ‘buy’ services from GPs and Hospitals (and other providers). The money is allocated on the basis of population size. However it is not distributed evenly as social deprivation has a strong correlation to healthcare needs and hence healthcare spending. How money is allocated is complicated – much of it is targeted or ring-fenced by the government and some of it is determined on a formula to allow for variations in need. Of the English NHS budget (around ~£70 billion) £21 billion is allocated according to this formula. What that means is this is not money spent on inequality measures but allocated on the basis of differing needs. And what’s it spent on? Well, everything the NHS does – hospital beds, operations, GP service, prescriptions etc.

As I said, it is impressively creative. A blatant lie, but a creative one.

NICE

The National Institute for Health and Clinical Excellence has a very difficult brief. They are charged with creating clinical guidelines based on the best available evidence in order to improve healthcare across the board and also to assess new therapies to see if they are both Clinically effective and Cost effective.

There are a lot of new cancer therapies that the drug companies keep bringing out. These drugs are often very clever and stem from a much better understanding of cancer biology at the molecular level. All of these drugs are very expensive.

In order to determine whether these drugs should be available on the NHS, NICE asks too questions; Does it work? (Clinical effectiveness) and Should we spend money on it? (Cost effectiveness). The second question is often the problem and as a clinician I have an instinctive distaste for the concept; my patient is ill, I want to make them better, this works and I don’t care how much it costs… However, whichever healthcare system you work in there are limited resources and hence the need to ask if therapies are cost effective. This is done using a methodology called QALYs (http://www.medicine.ox.ac.uk/bandolier/booth/glossary/QALY.html)

The concept is that a year of life lived at 100% health equals one QALY, whilst a year lived at 20% health equals 0.2 QALYs. The advantage of this approach is that is enables very unlike things to be compared such as therapies that treat disabling conditions against life-saving procedures. Ultimately it is impossible to put a value on human life. It is truly absurd. However in clinical practise where there is a limited pot of money – as there inevitably is, somehow we have to decide which treatments to use.

The interesting question is how much should the NHS spend per QALY gain?

To try and give some meaning to that here are a few examples (caution: the figures are made up by me to provide context)

Hip replacement
Patient aged 65
Life expectancy 15 years
QALY score without treatment; 0.4 x 15 years (i.e. an arthritic hip seriously decreases the individuals quality of life)
QALY score after hip replacement; 0.8 x 15 years
(Quality of life increased from 0.4 to 0.8)
QALY gain (0.8 x 15) – (0.4 x 15) = 6
Cost of Hip replacement £3000

Cost per QALY gain: £500

Neonatal care
Premature babies are extremely expensive…
28 week premature baby (born 3 months early)
Life expectancy without treatment: 0
Life expectancy with treatment: 70 years
QALY score with treatment: 0.8 (some prem babies achieve approximately full health, some never do, the range is massive)
A ’28-weeker’ would typically be in a NICU unit for 12 weeks at a cost of around £10,000 / week
QALY gain: 0.8 x 70 – 0 = 56
Total Cost: £120,000
Cost per QALY gain: £2150

Monoclonal antibody based chemotherapy for kidney cancer

Patient aged 38
Life expectancy without treatment: 3 months
QALY score 0.7
Life expectancy with treatment: 27 months
QALY score 0.5

QALY gain: (2.25 yrs x 0.5 QALY/yr) – (0.25 x 0.7 QALY.yr) = 1.125 – 0.175 = 0.95
Cost of treatment: £40,000 / year – total of £90,000

Cost per QALY gain: £95,000

[As I said, the figures are used purely to give context and I made them up myself. They are approximately accurate and there are studies out there that formally perform these calculations and then NICE makes a recommendation based on them.]

So what threshold would you put for deciding whether a treatment is cost-effective?

NICE typically works to a threshold of £20,000 – £30,000.

Ultimately we have to have a way of decided what to fund and what not to. Whilst the QALY method is undoubtedly crude, I don’t think there is a better one.

So let’s look at the NICE decisions, The Mail is complaining about – I looked up the NICE rulings on two of them:

Sorafenib

This is a drug for advanced HCC (a type of primary liver cancer). NICE concluded that the drug does improve life expectancy – the median survival advantage is 2 ½ months. So patients given this drug improve their prognosis from 14 months to 16 ½ months. At a cost of £51,900 per QALY gained.

Lepatinib

Lepatinib is used for advanced breast cancer. However it is only suitable for a minority of patients with this disease. The conclusion was that Lepatinib is clinically effective and improves mean survival from 17.6 weeks to 27.1 weeks. At a cost of £67,847 per QALY gained.

Why this article makes me so angry.

There is a vitally important debate underlying all of this. The question of what we as a nation and a society are prepared to spend on healthcare resources is vitally important. It is very difficult to decide whether end-of-life drugs are useful or not and there is no doubt that an extra few months spend with loved ones is extremely valuable.

However every £1 spent on one of these massively expensive drugs which have very limited benefits is money that cannot be spent on other healthcare spending. I think that part of the answer is that we should, as a nation, be prepared to spend more than we do but that’s my personal view. I also think that whilst drug companies are entirely legitimate in seeking to make a profit, some of the mark-up on medical products is simply immoral. What angers me is that this kind of article with all its inaccuracies has two effects; firstly it makes proper debate much more difficult and secondly it induces significant (and usually misplaced) anxiety in cancer patients and their families. And that to me, as a simple clinician is evil.

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