Wednesday, June 24, 2009

More NICEties

Sorry to have been silent for so long. The chemotherapy wipes me out for a few days, but today I am on the mend. I have been gradually working through a number of articles in WORD and they will be posed over the next few days.

I understand that NICE have agreed that Revlimid should be paid for for the treatment of Myeloma, even though the cost per QALY is £43,000 (around $70,000). This is good news for CLL patients, though we wait to see how the economics will play out for CLL.

The myeloma people tell me that it has been quite difficult to recruit for the myeloma trials with the greatest difficulty coming from the West Midlands around Birmingham. So I was not surprised to hear a radio comment from Birmingham expressing dismay at the NICE decision. The speaker apparently believed that the money could be better spent of statins for everybody over 50 to prevent heart attacks and strokes. He is probably right in that the cost of statins is extremely low - around £7 ($11) a month. But he is wrong on several counts.

First, the NHS is basically a state funded insurance system. It exists on the premise that what you can't do for yourself the community will do for you. Few of us could find a quarter of a million for marrow transplant, but as a community, that transplant will cost us 0.4 pence each. We can afford a lot of those. In belonging to a society we agree to spend a few pennies each on a wide variety of enterprises - roads to travel on, schools to educate our children, an army and police force to protect us, and public health measures to prevent epidemics. Different societies differ by how much of this community support is provided privately and how much by the state, but in all societies individuals have to rely on the whole. I doubt that many would be happy about the military or the police force being provided by industrial companies, but in some lawless communities that may be the best option.

There is also a decision to be taken on thresholds. How much does the individual want to buy from the community for each of these services? Private refuse collection versus personal visits to landfill sites? Home schooling versus inner city schools? A Montana campsite and an AK47 versus New York's Finest? In the UK we have opted for more state provision of services than in the US, but less than in Sweden or Denmark. Where the threshold lies does not affect the principle of the social contract; it is there to insure the weakest against the highest costs. It therefore makes no sense for the NHS to pay $11 a month for a pill to protect citizens against heart attacks when if that is what they want to do they could easily afford to pay for it themselves. On the other hand treatment of myeloma with Revlimid is beyond the reach of most people unless the rest of the community join in.

There is a second reason why the NHS paying for statins is wrong, and it goes to the whole basis of insurance. When the NHS was first introduced it provided free hot water bottles. Now 1947 was a very cold winter and there was no central heating in the UK then. There might well be good public health reasons for providing everyone with a hot water bottle, but why should people not buy their own? In fact, even Nye Bevan saw the silliness of this and it was stopped.

When I insure my car or my house, I elect to accept an excess. This means that the first £100 or £200 of the claim I pay myself. Naturally, I don't make small claims. Although, I get benefit from paracetamol (acetaminophen) when I am receiving chemotherapy, I would not dream of asking for a free prescription for it. At less than a dime a day a think I can afford it. Those who volunteer to have an excess get lower premiums - there are not so many claims therefore they pay less.

The third reason that the NHS should not pay for statins is that strokes and heart attacks are largely self-inflicted wounds. What is the point of spending $11 a month when the customer is spending more than that on cigarettes and fatty foods to counteract their effect?

The final point I want to make is about personal freedom. People who have opted for cigarettes and whisky rather than statins have already taken a decision about their health. Bib Brother has no right to gainsay it. By all means educate people into making good restrictions; even prevent manufacturers from influencing people with biased propaganda (as cigarette advertising was banned), but when someone says they would rather enjoy a particular lifestyle than possibly prolong their time in an old people’s home, they must be listened to.

The nanny State can intrude too much. It starts by offering help and ends up being compulsory.

No comments: