The cost of treatment is one of the biggest areas of the NHS budget and, whilst it is not often discussed openly, such costs need to be managed and controlled just like any other expenditure. However, given their implications for people’s health, such decisions need to be approached with care and taken in a consistent manner. Neither elected politicians nor frontline clinicians can realistically be expected to do so. In the case of the latter the cost of treatment cannot be considered directly if healthcare professionals are to maintain the trust of patients. David Cameron’s ‘Cancer Drug Fund’ provides an example of the problem in the case of the former. Simply put, the fund circumvents NICE – the body responsible for considering the cost effectiveness of treatments – and the principles that guide decision-making about the affordability of expensive drugs. This fund illuminates something of the difficulties that occur when, for one reason or another, debates about the allocation of resources become politicised.
Whilst creating the fund was, generally speaking, a winning political stratagem the consequence is that its decisions are inexorable linked to its political motivated origins. If it funds an expensive drug, it reflects well on Cameron, if it does not it reflects badly. Given we live in an era of cuts and austerity it is surprising that, despite the fund’s annual budget of £200 million, it may have overspent by as much as 180 million. In what is likely to be a futile attempt at preventing this from happening again, it appears that a number of drugs will no longer be funded. Despite extensive political criticism of the fund and the fact that many commentators consider it to be an ill advised policy the Labour Party have recently announce that, if elected, they will create their own ‘Cancer Treatment Fund.’
As other debates have shown, treatment funding is not just a matter of ‘headline’ budgets or even the cost effectiveness of particular treatments. Recent reports suggest the NHS will need extra £65bn by 2030 and, given current attempts to do more with less, it is clear the NNS is already reaching the limits of is finances. Whilst the plan was abandoned almost as soon as it became public knowledge the Northern, Eastern and Western Devon Clinical Commissioning Group (CCG) recently considered proposals to restricted routine surgery for smokers or those who’s Body Mass Index (BMI) was more than 35 in order to cut costs. The same commissioning group was one of a number who have been considering the allocation of hearing aids for similar reasons.
In addition concern about costs seems to have lead one GP surgery to encourage patients to go elsewhere if they need treatment for particular ailments. In light of these development it is difficult to see the proposal that dialysis cease to be a prescribed service, organised and paid for centrally, and instead become something devolved to CCG’s as anything other than an attempt to make savings, potentially at the expense of the provision of an essential and life-saving service. Indeed there is a distinct possibility that making provision for dialysis at the local rather than national level risks creating a postcode lottery - one of the problems NICE was created to prevent.
Lauren Laverne’s Christmas wish notwithstanding, we will never have an NHS without funding issues and controlling them will only ever be part of the story. One commentator has recently suggested we charge for seeing a GP but not only does this contradict the principle that the NHS be free at the point of use, it is little more than another prescription charge. It will not significantly alter the bigger financial picture and may make matters worse if the condition of patients significantly deteriorates whilst they consider if they can afford the upfront costs. Whilst there is good reason to think that we need to make sure patients use NHS services appropriately, given that many already attend Accident and Emergency departments because they cannot get an appointment with their GP, organising medical care in such a way that further discourages use is likely to be counter productive. Patient’s health will deteriorate and they will cost more in the long run.
One way that spending might be decreased through reorganising medical practice would be to properly fund social care. As Atul Gawande noted in his recent Reith Lectures, hospitalisation and high-tech medical interventions at the end of life is more expensive and less successful than what can be achieved if palliative and social care for these patients is integrated and provided with the proper funding. Similarly, a contributory factor in the perhaps not so recent crisis in Accident and Emergency Departments around the country has been ‘bed-blocking’ by patients who are ready to leave hospital but do not have anywhere to go if they are to receive the care they need. In this context, where the population is aging and chronic illness is rising, and when paramedics find themselves acting as community nurses or social workers, the issue is not just a matter of funding existing services but redesigning them to so that they meet our current needs.
Of course it is far easier to suggest such things than it is to make them a reality. Nevertheless, the first step is to start a conversation and engage in broader debate. However despite – or perhaps because - the NHS is something of a national religion dispassionate consideration of the best way forward is often notable by its absence. Our political leaders prefer the politically quick but superficial fix offered by Cancer Drug Funds. Furthermore if, as recently reported, Ed Miliband and the Labour Party plan to ‘weaponise the NHS’ in the run up to the General Election there seems little chance that less partisan - but no less interested - voices will prevail as they perhaps did in the creation of NICE.
For my own part I think this conversation will have to include a debate about what standard of care and treatment can the NHS afford. Is there a ‘ceiling’ on the care the NHS can provide? At the moment NICE makes these decisions on a case-by-case basis, but perhaps there should be more general principle. Whilst a large proportion of the public seem willing to pay higher taxes to fund the NHS, there seems to be a lack of political will to implement such a policy. At the same time a relatively small proportion of the UK population have some form of private health insurance. Perhaps it is time to give serious consideration to a healthcare economy that is constituted on the basis of dual sources of funding.
At the moment those with private means or insurance can skip queues, but it seem that the NHS still picks up the slack (and the bill), particularly in emergencies and when something subsequently goes wrong. In the first instance private medical care needs to be fully costed and follow up needs should be covered. In the second instance, it may be that some forms of care are no longer subject to NHS funding. Whilst both dentistry and opticians provide some historical precedent for this approach this may not mean eliminating forms of care currently provided for. Instead it may mean placing an embargo on new drugs over a certain cost-benefit threshold. This might mean that they are available only to those who can afford expensive insurance policies. But it might also mean that pharmaceutical companies focus on the treatments we really need, like new antibiotics, rather than those which have the greatest potential dividend.