TL: Conservative groups in the U.S. allege that the NHS puts a price tag on a person’s life, at $22,750. Is that true?
AD: Treatments are recommended if the benefits to patients are worth what the NHS is asked to pay by the manufacturers of the intervention. There is a limit on what the NHS has available to spend overall, but we don’t put a limit on the amount the NHS can spend on an individual. People get confused by the ratio—pounds per quality adjusted life year (QALY)—that we use to assess value for money. The QALY puts into money terms the value of health care that can be funded by the NHS, that’s being used up by agreeing to introduce a new, more expensive treatment. It is not a maximum budget for an individual patient. For example, some could cost a few pence a day but offer so little value that they aren’t worth buying. Something else could cost many tens of thousands of pounds a year for each patient but be so effective that it makes sense to make it available.
TL: What is the most controversial decision you have made?
AD: There are two—drugs for Alzheimer’s disease and drugs for end-stage renal cancer. In the case of Alzheimer’s disease, our initial stance was to reverse an earlier recommendation. However, after hearing arguments from the manufacturers, patients, and professionals, the decision we eventually made was to recommend its use in the moderate stage of the disease. That’s where the evidence told us it had its effect. Many people criticized us and said our decision meant that people had to deteriorate before they could get treated. But the sad truth is that people living with Alzheimer’s will inevitably deteriorate whether or not they are given drug treatment. We felt that it was more honest to treat when there’s a chance of an effect than to treat when there is little or no chance of a worthwhile effect.
It was a very hard argument to get across, and it outraged the clinical community. We were accused of actually causing patients to deteriorate when they would otherwise not. In offering treatment you have to be confident the drug will provide a reasonable amount of benefit, or you are generating false hope. We’re starting again on this one to see if any new evidence has accumulated over the last couple of years which might influence our current recommendations.
TL: What about the end-stage renal decision?
AD: Sutent and the other three drugs we looked at for treating end stage renal cancer were at the opposite end of the cost scale from the Alzheimer’s drugs. They extended life, but at a very high price. We would have to give up a lot of other health care to buy them. We initially said no, but we were uncomfortable about it because of the extra life that people could get. So we looked at our approach to valuing treatments which extend life at the end of life, and did a bit of recalibration. That enabled us to recommend one of the four drugs, Sutent.
TL: Don’t most new treatments offer something new?
AD: Yes, most things have something new to offer. The issue is not whether something is new or different, but whether that difference has any real value to patients, and whether it’s worth the other health care we could buy, but which we will have to forgo. In practice, we find sufficient value in most of the things we look at to recommend use in the NHS.
TL: What kinds of recommendations have you made?
AD: Of the 350 individual recommendations (in 170 technology appraisals), 84 percent recommend use of the intervention in whole or in part. It’s a pretty good rate. Obviously the companies selling the new products would like us to say “here’s a new product, let’s just use it the way its license suggests it should be used.” The intelligent approach, though, is to take a look at what’s being offered and see what value it adds and then optimize its use by targeting at those patients who can gain the most benefit.
TL: Can you be specific about the types of recommendations you make?
AD: Twenty-nine percent are unrestricted recommendations. That means the interventions can be used across the full range of the licensed indication. For 55 percent of the recommendations, we find that the new treatment benefits some patients—for example, those with advanced disease or that several drugs do the same job—so buying the cheapest makes sense. So we optimize the advice to reflect this.
TL: What about the other 16 percent of your recommendations?