There are often arguments about the approval of medical interventions in the UK, particularly about whether or not doctors are allowed to prescribe certain medicines. We hear from time to time that NICE – the National Institute for Health & Clinical Excellence – has blocked a treatment, or conversely has allowed it. I thought it may be interesting to introduce you to one of the key elements they consider when coming to their view; I accept that some of you will know more than me about this but, as a lay person, I think it is worth sharing.
NICE look at a treatment and ask themselves just what benefit it will bring, at what cost. The tool they use is the QALY, the Quality-Adjusted Life Years measurement. Rather than provide my own interpretation of the QALY, I offer you a quote from the NICE website (I acknowledge their ownership and authorship of this section):
How a QALY is calculated
Patient x has a serious, life-threatening condition.
- If he continues receiving standard treatment he will live for 1 year and his quality of life will be 0.4 (0 or below = worst possible health, 1= best possible health)
- If he receives the new drug he will live for 1 year 3 months (1.25 years), with a quality of life of 0.6.
The new treatment is compared with standard care in terms of the QALYs gained:
- Standard treatment: 1 (year’s extra life) x 0.4 = 0.4 QALY
- New treatment: 1.25 (1 year, 3 months extra life) x 0.6 = 0.75 QALY
Therefore, the new treatment leads to 0.35 additional QALYs (that is: 0.75 -0.4 QALY = 0.35 QALYs).
- The cost of the new drug is assumed to be £10,000, standard treatment costs £3000.
The difference in treatment costs (£7000) is divided by the QALYs gained (0.35) to calculate the cost per QALY. So the new treatment would cost £20,000 per QALY.
OK so far? The next step for NICE, having arrived at the calculation of the cost per QALY, is to decide whether or not this per-QALY price offers value for money. To achieve this, they have a simple formula. If the price-per-QALY is below £30,000 the treatment is likely to be approved. If it is above £30,000 there would need to be an extremely compelling reason to approve it, probably on a case-by-case basis, otherwise it would be classed as being not cost-effective and would effectively be banned.
I understand that different standards apply to end-of-life treatments.
What this boils down to is a calculation that says that a whole additional year of perfect health is worth spending £30,000 to achieve, or two additional whole years at a 50% improvement, or 4 additional whole years at a 25% improvement over standard intervention. It assumes that you can predict the additional life-gift of a treatment, and can also accurately measure quality of life. If your treatment would offer you 3 years additional life, with a health improvement of 25% compared to standard treatment, at a cost of £30,000 you would almost certainly be denied access to it, because it is not cost-effective.
The reason I am blogging about this now is that the government is about to change the way the NHS is run – GPs appear to be in line for access to most of the treatment money and will be allowed to make their own decisions about how and where to spend it. If a GP doesn’t believe your quality of life will benefit, are you more or less likely to receive treatment? And what (here is my special interest) about people with mental health problems? GPs vary in the extent to which they are psychologically minded. Some will readily see the benefits that a therapeutic intervention offers whilst others will be quite dismissive. With Valium costing around £0.01 per tablet to produce, is the GP more likely to prescribe that drug rather than psychotherapy at over £50 per session?
Whilst NICE have tried to apply science to the conundrum, I am fearful that we will end up with a free-for-all. I remember once bidding for some funding for a therapy service enhancement, only to lose out to a local GP who wanted to set up a rectal bleeding clinic. The money went to the squeaky wheel, not based on any attempt at service need evaluation.
Anyway, I offer you this so that you too can consider just what a year of your life might be worth and might be better armed when you do see your GP and make the argument for the life quality improvement you anticipate.