Patient is to appeal High Court ruling on breast cancer drugBMJ 2006; 332 doi: https://doi.org/10.1136/bmj.332.7539.443-c (Published 23 February 2006) Cite this as: BMJ 2006;332:443
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The only absolute legal duty placed on the Secretary of State for
Health and Primary Care Trusts (PCTs) is that they stay within financial
balance. PCTs are also required to establish rational decision making
processes in order to decide which services are to be developed within the
fixed resources allocated to them in any given year.
The Government has made cost-effectiveness a cornerstone of the UK
healthcare system. With that in mind, PCTs and the National Institute of
Health and Clinical Excellence (NIHCE) have been tasked with ensuring
services deliver health benefit at reasonable cost.
Given this, it is not clear what the Minister meant by her statement
‘PCTs should not refuse to fund Herceptin solely on grounds of its cost’?
There can be no question that it refers to financial consideration but
what type of consideration – there are a number of options:
Price – Herceptin certainly is one of the more expensive drugs on the
market for the treatment for a common condition. Per se is rarely a
Cost-effectiveness - Early estimates suggest that the QALY for
Herceptin may be well in excess of £100,000 – more than three times
NIHCE’s current indicative threshold of £30,000 per QALY above which
treatments would not normally be funded.
Affordability - A drug would be considered unaffordable in absolute
terms if it had the ability to break the NHS bank if all potential
beneficiaries were funded. Past examples include Viagra and the statins,
both of which were vigorously controlled when they came onto the market.
Treatments may also be deemed unaffordable in the moment. Are PCTs who are
taking out loans to pay healthcare staff seriously expected to even
consider funding Herceptin?
Opportunity cost - Treatments are deemed relatively unaffordable when
the opportunity costs are considered to high. This is generally a decision
made year on year and requires consideration of the amount of money
available to spend (which varies), priorities for service development
(which also varies year on year) and then cost and cost-effectiveness of
each service development (which can also vary as more information comes to
light). Herceptin may well sit on the cusp of being relatively
unaffordable. No one denies that the drug works but the cost of treating
all HER2 receptor positive patients would require a very large percentage
of PCTs available growth monies this year which will leave little for
other service developments.
Money is a major means by which this Society secures health and
quality of life for its people. And the needs are many. Health does have a
price however unpalatable that might be. To pretend that this is not the
case risks profligacy and poor decision making. It bears repeating that
the money allocated to the NHS can only be spent once, and we must not
ignore those who have no voice or the health gain associated with health
service infrastructure (e.g. the appointment of doctors or nurses).
Herceptin represents a challenge to Society. To rush a decision on
funding ahead of licensing and NICHCE’s assessment is neither wise nor
rational. Given the above it is also hard to see how financial
considerations, in particular opportunity costs, do not play a major role
in any funding decision.
Competing interests: No competing interests