The Independent - United Kingdom ; 13-Jul-2000 12:00:00 am
IF YOU, as an NHS patient, were offered pounds 10,000 a year to spend in any way you chose, what would you buy? Clearly it depends on what your problem is - but only partly, not entirely. One patient might opt for surgery, while another drug treatment. A third might prefer extra nursing care, while a fourth might select the distraction of a world cruise. There are more ways than one to improve health.
The question has a special poignancy for multiple sclerosis sufferers, who last month learnt that the National Institute for Clinical Excellence (Nice), the Government agency set up to monitor new treatments, is minded not to recommend the drug beta-interferon for use on the NHS.
If the recommendation is confirmed when the institute issues its final guidance, expected next month, beta-interferon - the only drug so far shown to be effective against the progressively debilitating disease - will in effect be banned on the NHS.
Unsurprising, then, that the patient organisations and lobbying groups, some funded by the drug's manufacturers, have been out in force since Nice's "provisional determination" was leaked last month. They have sought to portray Nice's members and its chairman Professor Michael Rawlins as flint-hearted bureaucrats who have wilfully ignored the awful suffering endured by the UK's 85,000 MS patients.
The institute concluded that the benefit gained from use of the drug appeared too modest to warrant its cost to the NHS. Although the price of beta-interferon is around pounds 9,000 to pounds 10,000 a year per patient, the real cost is higher because only a proportion of patients who receive it reap the benefit. About 40,000 of the 85,000 MS sufferers have the relapsing-remitting form of the disease, for which beta-interferon is indicated, but only 8,500 to 10,000 are thought capable of benefiting from the drug, based on criteria drawn up by the Association of British Neurologists. Only a proportion of those - and it is not possible to tell in advance which ones - will improve on the drug.
There is some argument about whether Nice has miscalculated the costs of the drug, by underestimating the length of time over which it is effective. An article in the journal PharmacoEconomics suggests the improved quality of life brought by the drug, allowing for the fact that not all patients who take it benefit, would cost pounds 28,000 a year, compared with up to pounds 1m estimated in previous studies.
What the article does not ask is why the drug should be so expensive. Drug companies traditionally justify the high cost of drugs by the need to recoup their heavy investment in research. But if the price of beta- interferon were halved, Nice might see its way to recommending it, multiplying sales and profits. According to the manufacturers, it is a costly drug to produce, but that does not explain why it is more expensive in the UK than in most other countries in the world, where, we are told, it is more widely prescribed.
While the actual costs are clearly crucial to this specific debate, the general argument about how we spend the available cash for the NHS cannot be ducked as it has been for the last 50 years. This is a question about cost-effectiveness, not about affordability. It is a poor nation, in more ways than one, that cannot afford to spend pounds 10,000 a year to ease the suffering of MS patients. But it is a foolish and irresponsible nation that does not look critically to see that that pounds 10,000 buys the maximum possible benefit for the patients whom it is intended to help.
One London director of public health told me of a trial of beta-interferon that was besieged by MS sufferers wanting to get on to it, including many who had already tried the drug and found it no use. What they were after was the extra support and medical attention given to participants.
With pounds 10,000, you can buy a lot of nursing care, physiotherapy
and aids. That is not as glamorous as a miracle drug, even one that does
not cure, but temporarily arrests the condition. But it may in the end
matter more to more patients.