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The problem of the fair distribution of health care resources.Image

This title headline was one of a number of press reports resulting from the request by the Department of Health that NICE takes the “wider societal benefits” into account when approving new drugs, as well as considering the burden of illness and the impact a disease has on patients. This has led to fears that groups such as the vulnerable and the elderly, who may be presumed to contribute less to society, could have their funding for treatments slashed.

NICE [ see my book p71-72] [stands for the National Institute for health and Care Excellence] is an independent organisation which was in part set up to end the ‘post code lottery – where some health organisations in some areas funded treatments such as IVF and other areas did not. The NHS budget is limited and hard decisions have to be made on what is funded and what is not. It cannot fund all the treatment that could possibly benefit everybody. For example should the NHS spend £50,000 on a treatment that extend a cancer sufferer’s life by 6 months or spend £50,000 on statins [drugs that lower cholesterol] ‘which would probably extend a number of lives but seems to give no immediate, obvious benefit.? What constitutes a need rather than a want is often difficult to decide. Most people might agree that breast implants and most cosmetic surgery should not be funded by the NHS but what about ugly scars or ‘fixing’ the protruding ears of a boy being teased about them?

How NICE looks at spending NHS resources in the fairest way possible.

Nice looks at QALYs [Quality adjusted life years] to decide if treatments should be funded. On average if a treatment costs between £20,000 – 30,000 for every extra good quality life year added it is funded by the NHS.However, decisions about whether certain interventions should be recommended are not based on the evidence of their relative costs and benefits alone. NICE considers other factors when developing its guidance.

Qaly league table

The 4 pillars of medical ethics are [further details in my book Medical School Interviews p74-79]

  •  autonomy – this recognises the rights of individuals to make informed choices  and gives rise to the concept of patient choice and consent
  • non-maleficence -this principle is arguably the oldest medical ethical principle in human history: primum non nocere, which is Latin for “first, do no harm”.
  •  beneficence – Taken together with non -maleficence this means balancing the benefits and harms [the harm/risk ratio] when deciding whether an intervention is appropriate.
  • justice – this entails providing services in a fair and appropriate manner and complies with the laws of the country such as anti discrimination legislation

It is this 4 th principle that underlies this dilemma.

There are 2 approaches about how to distribute limited resources.

  •      1. a utilitarian approach, which involves allocating resources to maximise the health of the community as a whole eg statins for hundreds rather an a life saving operation for for one person.
  • 2.an egalitarian individual needs approach, which involves distributing healthcare resources to allow each individual to have a share

NICE does not subscribe fully to either approach, and instead judges cases and situations on their individual merits. It enables health care decisions to be transparent. It has now been asked to take into account the ‘social benefit’ of treatment. This could lead to a slippery slope where as newspapers have pointed out certain groups could find it harder to access treatments.  NICE chief executive Sir Andrew Dillon has been quoted as saying: “We have no intention of introducing a change to our methods that would disadvantage older people.” It is also against the law to discriminate against groups of people such as the elderly and disabled. Is this fair? What do you think?