Just in case we thought Keynesian economics might protect us from the credit crunch, Nick Timmins of the Financial Times used his keynote presentation at an anniversary event for world class commissioning to demonstrate that we will be highly unlikely to enjoy growth reaching 3 per cent by 2011.
With the annual£100bn expenditure on health services now approaching 29 per cent of all departmental spend, even a 1 per cent increase becomes a substantial sum of money. The NHS will have to compete for funding.
World class commissioning prepares us for this, with its emphasis on wise investment, designated priorities to deliver health gain and reduce inequalities and an entire competency dedicated to prioritisation. It is a timely approach, but one not yet widely adopted in the department that spawned it.
Prioritisation requires a clear-headed assessment of local need, effectiveness and the costs of competing interventions. It requires a willingness to say no.
But there have been several recent counterintuitive initiatives in the current fiscal context, including removing prescription charges from cancer drugs and the deal to commission blood disease drug eculizumab at£26m a year for no health gain.
However, the one with the greatest potential to undermine commissioning is national cancer director Mike Richards’ recommendation to the National Institute for Health and Clinical Excellence to change its guidance for technology appraisal to a ceiling of£70,000 per quality-adjusted life year for drugs and technologies in the last year of life. Announced on Christmas Eve, which may be why you haven’t noticed it, this drives a coach and horses through any attempt to commission health gain, or to claim return on investment.
NICE technology appraisal panels were previously advised that£27,000 per QALY should be considered the ceiling of cost-effectiveness. Given that once a technology is recommended by NICE it is then mandatory for the service to adopt it, this has driven increasing proportions of growth into interventions delivering minimal health gain. Assorted economists have argued this ceiling is already too high and should be limited to£12,000-15,000 per QALY.
Even stranger is the focus of spending the most amount of money on those interventions that will by definition deliver least health gain - those given knowingly in the context of imminent death.
Admittedly, Professor Richards faced a challenging situation in the top-ups debate. He has helpfully clarified that private medicine remains private and cannot be confused with NHS treatment. There are no limits on privately paying for a drug or intervention that has not passed a commissioner’s assessment of its cost-effectiveness. This maintains a clear prioritisation approach in public services, designed to deliver the stated government priorities of reduced mortality and inequalities.
By promoting the effective removal of a ceiling for QALYs in pharmaceuticals administered at the end of life, Dr Richards pulls off a superb sleight of hand. He has reinforced existing NHS guidance on separation of private and public healthcare, but also removed any need for patients to purchase their own interventions of limited effectiveness, because now we have to do it for them.
This approach has a range of obvious consequences. Recent growth in expenditure on treatments mandated by NICE has driven out investment on competing local priorities. Even within cancer treatment, oncology drugs have taken the lion’s share of investment at the expense of the more effective upgrading or replacement of linear accelerators for radiotherapy. It is difficult to see how this is sustainable.
The focus on cancer interventions could have a particularly negative impact in diverting investment away from interventions that may have greatest impact in tackling health inequalities. Premature mortality is driven by high infant mortality, typically in deprived populations, and by early deaths, typically from cardiovascular disease, again in deprived populations. Despite the media face of cancer, it is a disease where prevalence increases with age, among those who have avoided early death from CVD - typically the wealthier. Mandated spending on cancer drugs, particularly those defined as palliative, may actively sustain health inequalities.
Such arguments are inevitably technocratic and difficult to sustain in the face of individual tragedy. How much worse is it then if this additional expense also potentially makes worse the quality of one’s experience.
Over 65 per cent of people would prefer to die at home rather than in hospital.
But treating cancer patients at end of life with drugs typically billed as lifesaving means the patient continues to be treated as acute. It becomes even more difficult to initiate honest conversations about preparation for death. This maximises the likelihood of death in hospital following an unplanned admission. Creating greater availability of drugs of limited cost-effectiveness at the end of life means not only will our deaths cost more, but we shall continue to have bad death experiences.
There is a possibility, of course, that this is a seriously clever intervention. To date, one of the greatest challenges in improving end of life care has been the difficulty in persuading doctors to identify patients who are likely to die in the next year. If oncologists want to use newly available drugs, they will have to identify the potential patients as dying. Once formally identified as dying, there is every possibility the patient will have better things to do with their last three months than make endless visits to hospital to receive highly toxic substances. They may even want to discuss pain control and the chance to die at home with the palliative care team.