The funding of the NHS is a political hot potato. It has been a contentious issue even before the service first launched way back in 1948. Points of alignment between opposing politicians, doctors, tax-payers and patient representatives have been few and far between. Not only do we have disagreements about how money comes in but also how and where it is spent. As a result we have all four of the home nations – England, Scotland, Wales and Northern Ireland – on very divergent paths. How should we pay our doctors? How should we organise funding of hospitals? How should we organise decisions about what services to offer?
Healthcare is an arena for stunning innovation on a regular basis. It may even be that the pace of these innovations is accelerating and with ever increasing momentum. The possibilities are incredible – yet the associated challenges seem increasingly insurmountable as uncomfortable, painful dilemmas come into focus.
At the end of January The Lancet Oncology reported a study that proton beam therapy is as effective in children as conventional radiotherapy, and has fewer side-effects. You will remember that this is the treatment at the centre of the highly emotive 2014 Ashya King controversy. On one hand this is fantastic news. On the other, innovations of this nature lead to big questions: money, staff numbers, time and space available are all finite resources.
How much will the equipment for this new equipment/treatment cost to purchase? What are the associated costs of training doctors/operators/technicians? How often will it be used? Even if we can afford to buy the equipment how do the running costs/treatment times compare to what we currently have? If we do purchase it then where will we put it? Does something have to be moved out to make way? What will we do with the patients that were best served by that treatment method? What else do we need to consider?
Shona Robertson, the Scottish health Secretary announced an independent review of the ‘value for money’ assessment process for drugs in Scotland on the same day that the proton beam therapy study hit the news. At the end of any such assessment, the fundamental economic decision which has to be made sounds uncomfortably harsh: ‘We know it will help this patient – is it worth it?’ How can we comfortably make such decisions?
The field of economics is more than pound, shillings and pence. It is ‘the social science that describes the factors that determine the production, distribution and consumption of goods and services.’ Clinicians of all disciplines actually make decisions of this type on a daily basis. An example is the decisions on how much time to spend on a particular patient. We know that there could be direct benefits for the individual if we give them more time – yet there are only so many hours in a day and there are other patients. So we have to curtail the time dedicated to this individual in order to provide a quality service to the many. The decisions about approval for new treatments may seem remote as they are made in a different forum than daily, direct doctor-patient interactions, but they are fundamentally the same type of decision.
News stories of innovation, new techniques and therapies still have a very real day to day impact upon doctors in practise. They have a direct impact upon patient expectations and those of their relatives.
In addition to the decision making process itself, the Scottish independent review of the ‘value for money process’ would do well to consider the approaches to consultation and communication of decisions with all stakeholders: the fund-holders and hospitals; the doctors who will/will not be able to utilise the technique or therapy; the third sector and, of course, the media.
At the same time, doctors must continue to develop their abilities to have to factual, empathetic conversations related to economic decision with patients and relatives. Active interaction with an ‘value for money approval processes’ can only support this development.
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