What do you look for in a hotel? Whether on business or for pleasure, you’ll have some key ‘must haves’ in your value metric: cleanliness, a safe environment, suitable amenities. Under ‘nice to have’, you might include value for money, free Wi-Fi, or car parking. You might rate a bottle of champagne (with chocolates) on arrival as a ‘delighter’.
What about trade-offs? We are not generally happy to trade with our ‘must haves’ in life. So, if you find that your hotel room is not clean—dirty linen, a small rodent?—you will be straight ‘out of there’! Champagne, chocolates, or free Wi-Fi won’t really cut it. In essence, we don’t generally trade ‘must haves’ in our value metrics, even if someone offers us a ‘delighter’.
What does all this have to do with medicines? NICE has recently announced draft guidance that potentially rejects trastuzumab emtansine for breast cancer, because it does not offer value for money to the NHS.1 What we really need to ask is, what do patients value in a medicine? What are their ‘must haves’? It must work. It must make me feel better. It must be safe. What about ‘nice to haves’? Palatable, easy to take, few side-effects. As for ‘delighter’, how about cure?
The truth is, cost doesn’t come into any of these values: the concept of value for money is irrelevant for patients because they do not need to consider the cost of treatment (trastuzumab emtansine costs £90,000 per patient per year).1
So the ‘value’ discussion is still critical from a patient criteria perspective, but for conditions like cancer, what we are really talking about is ’hope’: there is an element of ‘let’s try anything, let’s try everything’, even if the chances of success are remote. The concept of cost/QALY2—whether a cancer drug is prolonging life or prolonging death—doesn’t feature for patients or carers. Everything is based on the extension of, rather than quality of life.
NICE has published its Value based assessment consultation3, by which the way we pay for medicines is about to undergo a revolutionary change. The cancer drug fund will disappear (as will the concept of end-of-life special circumstance to allow a high cost/QALY); instead, we will have a methodology that allows the NHS to pay for medicines according to the value they offer to patients (rather than the price the drug company is asking).
A very good friend of mine who has myeloma (he’s also a GP) told me that, after five cycles of chemotherapy and a stem-cell transplant, he would ‘never go through that again‘. I challenged whether his view might change if he gains a long remission. It was a heartfelt discussion between two best friends. But it is clear that, should he relapse sooner rather than later, he is unlikely to opt for an awful quality of life for the few extra weeks or months that the treatment may give him. We need to re-address value in a humane way and ask ourselves how we integrate life and death with health economics. And we need to do it now.
Omar Ali, Formulary Development Pharmacist, Surrey & Sussex NHS Trust
Men's Health Week: 9-15 June
Update your knowledge:
GP curriculum heading 3.07—Men’s health
To find out more about why ED should be regarded as an important marker for men’s health, read the article here
- NICE. Draft guidance on Breast cancer (HER2 positive, unresectable)—trastuzumab emtansine (after trastuzumab and taxane). Available at www.nice.org.uk/guidance/TAG/350
- NICE website. Measuring effectiveness and cost-effectiveness: the QALY. www.nice.org.uk/newsroom/features/measuringeffectivenessandcosteffectivenesstheqaly.jsp (accessed 9 May 2014)
- NICE. Centre for Health Technology. Consultation paper. Value based assessment of health technologies. Available at: www.nice.org.uk/media/FE2/2B/VBA_TA_Methods_Guide_for_CONSULTATION_upload.pdfG