The cost of treatment is one of the biggest areas of the NHS budget and one of the most sensitive areas of discussion. We would all like to have an infinite amount of money to spend treating diseases and prolonging life, but in reality these costs need to be managed and controlled just like any other expenditure.
Given the implications of funding this or that treatment, or spending more on one condition over another, decisions about where the money should go have to be approached consistently and taken with care. David Cameron’s Cancer Drug Fund (CDF) is a good illustration of why this is difficult for politicians to do.
The CDF provides access to drugs that NICE – the body responsible for considering the cost effectiveness of treatments – has deemed too costly despite their potential benefits. It has an annual budget of £200m to provide funds for cancer drugs that the NHS will not pay for under usual circumstances. However, the recent decision to increase the CDF’s budget but cut 16 drugs from the CDF’s list of medicines – heavily criticised, unsurprisingly, by cancer charities and pharmaceutical companies – illustrates the difficulties that occur when, for one reason or another, debates about the allocation of resources become politicised.
While creating the fund was a political winner, its decisions are inexorably linked to its creation. Given we live in an era of cuts and austerity it is surprising that, despite its annual £200m budget, it may have overspent by as much as £180m. Next year the CDF’s annual budget will rise to £340m. As a result the CDF will not only be criticised on grounds of expense, and for primarily benefiting pharma companies, but for the treatments it can no longer afford provide. Furthermore, it will continue to circumnavigate the principled decision-making of NICE.
The issues raised by funding treatments via the CDF misdirects our attention from the bigger issue: that the fund is a way of undercutting NICE and spending money that could be spent more efficiently elsewhere in the NHS. The treatments paid for by the CDF are not approved by NICE because they do not offer sufficient benefits given their cost. Given the current pressures faced by NHS services it is clear that the money could be spent to more, and better, effect.
A political hot potato
Despite extensive political criticism of the fund and the fact that many commentators consider it to be an ill-advised policy, the Labour Party recently announced that, if elected, it will create its own “Cancer Treatment Fund”.
As other debates have shown, treatment funding is not just a matter of headline-grabbing cancer budgets or even the cost effectiveness of particular treatments. While 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 restrict routine surgery for smokers or those whose 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 rationing of hearing aids for similar reasons. In addition, concern about costs seems to have led one GP surgery to encourage patients to go elsewhere if they needed treatment for particular ailments.
In light of these developments, it is difficult to see the proposal that dialysis cease to be a prescribed service, organised and paid for centrally in the NHS, and 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. There is also a distinct possibility that making provision for dialysis at a local rather than national level risks creating a postcode lottery – one of the problems NICE was created to prevent.
An impossible wish
Despite Lauren Laverne’s Christmas wish, we will never have an NHS without funding issues. Controlling them will only ever be part of the story. One proposal, which was made by Simon Jenkins in The Guardian, is to charge for seeing a doctor, but not only does this contradict the principle that the NHS must be free at the point of use, it is little more than another prescription charge. It will not significantly alter the bigger picture and may make matters worse if the condition of patients significantly deteriorates while they consider if they can afford an upfront cost.
While there is good reason to think that we need to make sure patients use NHS services appropriately, given that many already attend A&E 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.
Funding other types of care
One way that spending might be made more efficient 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 are more expensive and less successful than what can be achieved if palliative and social care are integrated and properly funded. As is the case with the CDF we focus our demands on new, high-tech and expensive drugs while the basics of health and social care are subject to neglect.
For example, a contributory factor to the recent A&E crisis has been “bed-blocking” – patients who are ready to leave hospital but do not have anywhere to go that meets their care needs. In this context, where the population is ageing 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 so that they meet current needs.
While there is an ongoing discussion of the merits of NICE adopting value-based pricing, even if it successfully delivers the lower prices it promises it seems unlikely to eliminate the politics of grabbing the headline.
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. Instead, our political leaders prefer the politically quick but superficial fix offered by cancer drug funds.