This week’s paper of the week is brought to you by Dr Tim Wilson, Managing Director
Full reference and title from the journal:
Chamberlain, C., Owen-Smith, A., MacKichan, F., Donovan, J. L., & Hollingworth, W. (2019). “What’s fair to an individual is not always fair to a population”: a qualitative study of patients and their health professionals using the Cancer Drugs Fund. Health Policy, 123(8), 706–712.
While patients and oncologists appreciated the drugs available through the Cancer Drugs Fund, most expressed concern about its fairness. Competing participant views about the added value of the end of life is challenging for resource allocation.
3V bottom line
Fairness in healthcare needs us to do two things- adopt a culture of stewardship, that is use resources for the good of the population as a whole and allocate resources to populations “reasonably”. Neither are present today as demonstrated by the Cancer Drug Fund.
3VH – Implications for value
The Cancer Drugs Fund was set up after pressure from various lobby groups and the media, notably the Daily Mail, persuaded politicians that it was right to allocate funds to treatments that would not normally pass the value for money test set by NICE (around £20-30k per extra quality adjusted life year). This is because the cancer treatments covered by the fund, but not by NICE recommendations, are primarily for people with incurable cancer providing a short increase of life expectancy (months), and often with many side effects.
First there is the issue of whether patients and their families were properly counselled on the pros and cons of treatment. Indeed, there is evidence that clinicians were over optimistic about the benefits versus harms of these cancer drugs.
Second, we need to recognise the money comes from somewhere. So, the government could take it from school or defence budgets, or it could come from within the health budget.
But, if we adopt a culture of stewardship, we would immediately recognise that providing treatment for one population group will deny another. Presently, whilst there is a formula to allocate resources in a fair way to geographical areas within England, there is no process to allocate funds to populations within those areas; hence we see a variation of between £22m per million and £93m per million on the spend on cancer across England. And that variation has worsened over recent years.
Making allocation decisions to populations is not easy, but all that is expected is that the decision made is “reasonable”. As Daniels and Sabin put it;
“the process must be public (fully transparent) about the grounds for its decisions; the decision must rest on reasons that stakeholders can agree are relevant; decisions should be revisable in light of new evidence and arguments; and there should be assurance through enforcement that these conditions (publicity, relevance, and revisability) are met.
But this weeks’ paper of the week demonstrates that patients and oncologists alike did not think the Cancer Drug Fund passed the test of reasonableness. It was not fair to others and the process of determining the fund was not transparent.
Until the health system starts to allocate funds to population groups reasonably and we adopt a culture of stewardship we risk unsustainable and unfair health and social care.