My mother was horrified when she discovered I’d become “one of those people who refuse patients drugs because they’re too expensive.” Barely a week goes by without another story in the media about someone somewhere who has been “denied” a treatment. Usually accompanied by a photo of them with their concerned relatives, the language is always emotive; the local PCT is portrayed as an anonymous decision-making machine and, above all, heartless and uncaring.
In an age of scarce NHS resources and spiralling treatment costs, it often falls to the public health department in PCTs to make the decision about whether or not to fund costly drugs or procedures. Far from the reflexive reaction the media suggest, decisions are taken at regular meetings, involving a variety of professionals, and follow fairly strict guidelines about the factors to be considered. The committee first refers to NICE guidelines, or if these aren’t available (as quite often happens) local policies and other appropriate evidence.
Making the transition from clinical medicine, where the priority is getting the best treatment possible for the individual patient in front of you, to the population perspective and utilitarian ethic of public health (seeking to provide the best care for as many people as possible) is tough. It doesn’t help that in hospitals money is pretty meaningless – although the prices are in a different league, who thinks about the cost when they put three venflons on the tray before going to see a patient, to save having to walk back to the cupboard if the first doesn’t go in? When did you last consider the price of a CT scan?
Eisai and Pfizer, who market the Alzheimer’s drug Aricept, have recently won a court case which will give them access to the economic model NICE uses to calculate whether a treatment offers value for money. NICE may be one of the most criticised organisations in healthcare, but they do at least attempt to appraise the evidence and provide a benchmark that can be applied nationally, to improve the consistency of decision-making. The court ruling doesn’t mean the drug will suddenly become widely available, but will phamaceutical research now miraculously now start to demonstrate costs within NICE’s threshold? The decision is unlikely to improve transparency generally and certainly won’t help the case of the PCT in the public’s eyes.
Rationing of costly therapies for a minority of patients isn’t going to go away: in the current economic climate, there isn’t likely to be more money available, and the costs (and number) of treatments for rare conditions are only going to escalate as technology advances. But next time you read a story about a patient being refused a treatment, stop and think about the decision – what would you have done, given the same budget constraints? How would you justify your decision? And perhaps you could just take two venflons in future. As the saying goes, “Every little helps.’