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Editor's blog (2) 18th August 2008: money for nothing to the Ritalin generation

Oh. For. Fuck’s. Sake.

I have just wasted half an hour of my life that I’m never going to get back again, watching the BBC Panorama programme on drug access and NICE.

Now 30 minutes is far too short a time to even attempt a serious programme about healthcare rationing if you’re clever and thoughtful (even though the BBC evidently believe that the attention deficit disorder generation, weaned on Ritalin and fast edits, can bear no more), so a serious programme is what we didn’t get.

At one point in the programme, Andrew Dillon, chief executive of NICE, told the presenter Shelley Joffre that her question was a “nicely tabloid summary” of the appallingly complex issue of dealing with age-related wet macular degeneration by the licensed Lucentis or the unlicensed Avastin (which is, of course, licensed for bowel cancer). For some reason, this is bringing thalidomide to mind.

He wasn’t wrong about tabloid. It was a tabloid bucket of ‘how do you feel?’ shit.

The editorial thrust of the programme was wholly uncritical of the concept that there may be any drugs invented that their manufacturers might want to charge more money for than can be justified by their utility.

It’s the ‘money for nothing’ argument, that says if a treatment can extend a life, we must have it. It’s a great argument to deconstruct with people. So if it costs £50,000 per patient (as the prioramme suggested one bowel camcer drug would cost a PCT for just two pateints), all should have it? OK.

Now another, better and more effective drug with less side effects and more health gain costs £250,000 per patient. That’s still fine, isn’t it? Because it’s only two patients? But hang on, cost inflation in healthcare is a bugger, and there's always another, better and more effective drug with even less side effects and even more health gain – and this one costs £950,000 per patient – and there’s an even better one still coming through, which will cost £13 million per patient.

Still OK with that?

The deepest mire of stupidity in the programme came when it sought to present the decision of the Scottish Medicines Consortium (SMC - Scotland’s NICE-equivalent body) to rescind its blanket acceptance decision on treating wet AMD in the light of further consideration of evidence – in line with NICE’s  uncomfortable but evidence-based prevarication – as a ‘conspiracy theory’. Which was to blatantly ignore the interviewed SMC official's statement that the decision had been changed in the light of further evidence. Post hoc is not propter hoc, however much dumb journalism may want it to be.

‘What’s the point of training me?’
This was the rhetorical question asked by one consultant, describing inequities of prescribing Avastin or Lucentis for wet age-related macular degeneration. In the light of his evident unwillingness to consider the impact of his decision-making on resource use, it stuck me as a bloody good question.

Almost every clinician wants to use the whizzy new ‘wonder’ drugs - so called because you wonder whether the manufacturers will price them at or above the usual NICE threshold of £30,000 per QALY gained. This is because sometimes, the ‘wonder’ drugs work really well, and will do the things the reps and PR people are telling you about (and won’t do too many of the disagreeable side-effect things these groups are studiedly not telling you about, or at least which hopefully won’t present so soon as you’d notice).

That is not the point. One option is for us to move to a ‘wonder’ drug religion approach: a faith-based system, where we forget about really examining the evidence, and just bang everybody onto the new drugs, and we’ll just cut their cost from public health, or mental health, or learning difficulty, or prison health budgets. (You know, the unsexy parts of healthcare, about which no-one is going to make a TV programme.) Because we believe in ‘wonder’. Christ, it’s like a theatre show of Peter Pan. “I believe in magic”. For some reason, this is bringing thalidomide to mind.

Or we can accept compromise, accommodation, and utopianism in the sense of the greatest possible good for the greatest possible number. Or consultants can accept that they are responsible for the allocation of resources – and that this may occasionally mean reaching the uncomfortable conclusion that some drugs which may be effective may also be more ecxpensive that can be justified.

But that isn’t going to make for easy, feel-good-indignation 30-minute prime time TV. It totally fails to ‘name the guilty men’, or to conclude that ‘something must be done’.

There will always be hard decisions to be taken in a resource-limited system. There will always be some telegenic young people whose stories about their illness are devastatingly sad, and who legitimately want to ask “if it was your own flesh and blood and you weren’t in a position to pay for it (the wonder drug) privately, don’t you think you should get it regardless of where you live?”

Because sometimes, the considered and rational answer to that question might be “no”. Uncomfortable as it will feel.