AD: Yes. No country can afford to fund anything and everything every citizen might feel they should have. All countries place limits on what is made available. Governments do, employers do, insurers do too. Most countries make sure their citizens have choices. People in Britain can decide to use the NHS, or they can take out private insurance. But most people who have private insurance also use the NHS.
TL: For decades, Americans have heard that there are long waiting lists for procedures. But hasn’t that changed in recent years?
AD: The NHS used to have long waiting times for elective surgery. With recent investment, people can more or less choose when they have their care. You can see a family doctor for routine care within twenty-four hours, and most non-emergency hospital care can be organized within a matter of weeks. Of course, all emergency care is both completely free and available on demand.
TL: How has that changed?
AD: The NHS has received significant additional funding. It has increased from around 60 billion pounds to around 90 billion over the last seven years. It is also better organized and better equipped.
TL: How much private insurance is there?
AD: About 12 to 15 percent of the population has some private health insurance. The number is going down because waiting lists are being eliminated.
TL: In other words, your government realized there was a problem and corrected it, is that fair to say?
AD: Yes, the NHS needed more money to provide the standard of care that people see available in other countries. It needed to fix the waiting list problem, and it needed more professional staff.
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?