Triggered by research carried out by the University of York, the BBC and other national media were recently reporting that the cancer drugs fund is poor value for money. The research in question stated that NICE has set its price threshold too high, critically stating that the cost per quality adjusted life year (QALY) should be reduced from £20,000 to £30,000 per QALY down to £13,000 per QALY.
The research gave the rationale that every time NICE approves a new medicine at the current threshold, it is in fact diverting necessary funds away from patients who need treatment and instead paying drug companies for medicines that are not cost effective.
I think all of us in the NHS can relate to the end-stage of this debate; having to deal with reductions in funding for care provision to patients, because we are paying hefty prices for new medicines. The real difficulty with this discussion is that it comes down to a simple question: how much is a life worth? The first answer is a reflex one—‘you can’t put a monetary value on a life’—yet the NHS is having to do this on a daily basis.
In a way, whichever cost to QALY ratio the NHS settles on is going to receive criticism because most of us, and certainly the general public, don’t want to say a person’s worth can be described by a five-figure number. Besides, someone’s life is actually valued in far more than just fiscal terms, so there is no cost/QALY that will ever do this justice.
However, we live in the real world where the NHS does not have infinite resources, and is going to have to state some fiscal cut off point for how much it is willing to pay for healthcare-related intervention. And how do we arrive at the current consensus of £20,000 to £30,000 per quality adjusted life year?
There are a number of ways we can derive this; but perhaps the most rational is to cost out the life expectancy spend threshold, and see if it is unreasonable. If we are willing to pay £25,000 per year of quality life, it suggests that a human being with a life expectancy of 75 years has a ‘human life value’ of just under £1.9 million.
In real terms, you can see both sides of the coin. I wouldn’t sell any of my three children for that sum of money; therefore, this figure does not reflect their value. However, I wouldn’t sell them for any value you may wish to quote, so we are back to the ‘you can’t put a monetary value on a life’ situation. Conversely, I would be lucky to gain a life insurance premium worth that amount.
The fact is, in the real world I couldn’t afford it. Having seen the values I would have to pay for my life insurance premium, even to fund up to £1 million, it is not worth it. So, when we look at the price we have to pay to preserve our health, the NHS cost per QALY is in fact willing to pay a price for human life, that most of us ourselves would not choose to pay.
This brings us to whether or not the current cost per QALY is too high. If I am not prepared to pay half that price for my own life insurance, should I expect the state, public taxes, and your own purse to do so? It is interesting when you look at it from the perspective of paying, rather than just looking at what we are entitled to.
Sir Andrew Dillon’s (Chief Executive of NICE) response was pragmatic: ‘Reducing the threshold to £13,000 per QALY would mean the NHS closing the door on most new treatments.’ So, in a way, we are competing between the willingness to pay for a life and the willingness for companies to reduce their prices. And in that, value becomes critical again. It all depends which side of the coin you are looking from, and to a lesser extent, the denomination, currency, and value of that coin.