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5 September 2011
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Advocacy, emotional blackmail or just good politics?

By Ronny Cheung

The FDA (US Food and Drug Administration) decided to withdraw approval for Avastin as a treatment for advanced breast cancer recently. They heard evidence from individual women whose lives had been prolonged by Avastin. However, they were unswayed, pointing to the $88,000 per year cost. It is yet another example of the longstanding debate about value judgements in healthcare and the role of advocacy.

Two things struck me, one slightly at odds with the other. Firstly, the value we place on health. NICE (the National Institute for Health and Clinical Excellence) use a threshold of £30,000 per QALY (Quality-adjusted life year) gained (albeit a somewhat flexible threshold) as the benchmark for approving therapies. Advocates argue for their point of view regardless of cost.

Secondly, the methods used to make difficult decisions like this are never as simple as most of us would think. NICE tend to argue that they have a rational basis for making decisions and the result of logical deductions should be respected whether you like the result or not. Advocacy promotes the idea that it is acceptable to use human stories to get what you want. After all, the squeaky wheel gets the grease, and there's only so much grease to go around these days.

Now that we have to make efficiency cuts of about 20% of the NHS budget, should NICE's threshold change proportionately? That makes financial sense - but then we are saying that when times are tough, cancer survival may have to go down? This is one area where "improving quality" isn't always cheaper, and surely we can't just carry on as we were. Should NICE embrace the tactics of advocacy and recommend treatments the health service may no longer afford, or is the proposal that they look at value to the whole system a better one?

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Ronny Cheung's picture

Ronny Cheung

Ronny is a Specialist Registrar in General Paediatrics in London. His main interests are in medical education and models of child health service delivery. He is currently editing the NHS Atlas of Variation for Child Health Services, to be published this winter.

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Comments

12 years 7 months ago

Thanks for your comment Mark.

Thanks for your comment Mark. I completely agree with you re. the importance of ensuring equity, and the concept of value being vital.
Although reducing unwarranted variations is a huge step to achieving better value healthcare across the board, we will still need to face up to the fact that newer, more expensive treatments will be subject to advocacy on the basis of individuals' lobbying power, rather than any overall sense of "value" to the system? The NHS is political, despite all the protestations to the contrary. The cancer drugs fund is a prime example of good advocacy, but not necessarily good value.

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12 years 7 months ago

Health Economic Evaluation

It is difficult to make decisions regarding competing therapies on the basis of cost per QALY, as significant numbers of therapies have not undergone cost-utility analysis. The other problem is that cost-utility analysis doesn't solve the problem of equity in healthcare delivery - it may be that a particularly expensive therapy benefits a very deprived population of people.

I believe the QIPP Rightcare workstream offers a useful paradigm by addressing inappropriate variation in healthcare delivery. Using the NHS Atlas of Variation, one needs only to look at the rate of knee replacements in association pre-operative EQ-5D scores in certain PCTs to realise that something is very broken in the system.

Addressing this unwarranted variation would go some way to potentially addressing economic shortfalls, equity and quality at the same time.

However, I would agree that NICE's threshold should reduce, and we should be making it our priority to fund therapies that offer the those therapies that are the "best value" to the UK population, despite high profile advocacy.

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