a problem of limited resources

a problem of limited resources

This title headline was one of a number of press reports resulting from the fact that a special Cancer Drugs Fund is overspent and 42 drugs are being reassessed as price caps are brought in for the first time.NHS England said the current system was unsustainable and that there were new drugs “that will do more for patients”. Drugs have to be cost-effective for the NHS to make them routinely available. However because of public pressure Prime Minister David Cameron set up a separate pot of money in 2010 to give patients access to expensive drugs, irrespective of cost.

Dr Mangesh Thorat, from the centre for cancer prevention at Queen Mary University of London, said: “This issue presents me with a dilemma.As a cancer clinician, I am happy that this Cancer Drugs Fund prevents my patients from being denied treatments towards end of their life, however, on the other hand I think this fund not only undermines NICE, but also discriminates against patients in similar situations who have diseases other than cancer.”

NICE [National Institute of Clinical 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 fundedand what is not. It cannot fund all the treatment that could possibly benefit everybody. For example should the NHS spend £100,000 on a treatment that extend a cancer sufferer’s life by 6 months or spend £100,000 on statins [drugs that lower cholesterol] ‘which would probably extend a number of hundreds 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 £30,000 for every extra good quality life year added it is funded by the NHS and double this for cancer and other end of life treatments.However, decisions about whether certain interventions should be recommended are not based on the evidence of their relative costs and benefits alone. NICEconsiders 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  – fairness, 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.

What do you think? Do you think cancer should be an exception;a special case. Do you think the cancer fund should be continued to provide treatment at any cost?