Opinion: How much is treatment worth?

22 April 2015

The toughest of tough decisions: those are the ones the National Institute of Health and Care Excellence (NICE) has to take.

As I argued some months ago in a post about that curious area of ethical studies, Trolleyology, the problem is that of deciding whether we are justified in sacrificing one person’s life to save several others. And NICE has to go further, having to ask how much suffering is it worth causing in others to save one life or, even more challenging, a single year of one life?

That was a question that made the headlines on 19 February, when the University of York published the report of a research study on the criteria applied by NICE in assessing whether certain drugs or treatments should be available through the NHS. Currently, NICE will adopt a treatment if it costs no more than £30,000 per Quality Adjusted Life Year or ‘QALY’. 

The QALY is a broadly accepted measure which takes into account the extra years of life provided by a treatment and adjusts them for any loss in quality the patient may suffer. For example, amputating a limb may provide extra years of life, but the quality of that life will be reduced by the loss of the limb.

As the authors of the York report point out, a £10 million spend by NICE at £30,000 a QALY would generate a total benefit of 333 QALYs. But this £10 million would not be available to other areas of the NHS, where a QALY costs around £13,000.

In other words, the same expenditure elsewhere could generate 773 QALYs against the 333 from the NICE-approved treatment. On balance, therefore, the new treatment would represent a loss to the NHS of 440 QALYs.

To be equitable, the authors argue, NICE would have to set the bar for adopting a new treatment not at £30,000 per QALY but at £13,000.

Why is the threshold set so high? Because, as the papers pointed out, the single patient denied a new and expensive treatment is highly visible. Individuals with life-threatening illnesses make for good copy in the papers and a great story for the six o’clock news, but the faceless people who have been denied treatment because money has been spent elsewhere are impossible to identify.

Somewhere, some respiratory disease sufferers, congenital heart disease patients or people with a mental illness have had their pain increased and possibly their lives shortened. But we don’t who they are, they can’t be interviewed and they can’t make their own case.

In Trolleyology, the issue is whether to throw a switch and send a runaway railway wagon down a branch line where it will kill one person, instead of the five who would die if it kept going straight ahead.