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When I use a word…. By DJMR

by on September 25, 2011

The founding principles of the National Health Service state that care should be free at the point of delivery and access to it should be based on clinical need, not on an individual’s ability to pay.  All of us will understand the concepts but I suspect few of us could formulate a clear definition of “need” – so it’s a great word for politicians to bandy around.  How does the modern NHS interpret “need” and to what extent does it live up to its founders’ pledge?

Attempts to define health need in the past have largely come up with negative statements along the lines of “the need to be free from ill health” but translating this into a guiding principle for a health service which can only temporarily and partially relieve ill health is difficult. Some conditions are simply not treatable, most can only be modified or palliated and only a surprisingly modest proportion can be cured (but always with the knowledge that at some unknown point in the future further ill health is certain).

Few of us would defend the use of public money to provide treatments that we know are of no benefit or even cause harm. We implicitly accept that a sick patient does not need a treatment from which they cannot benefit. At the other end of the spectrum we do expect the NHS to fund treatments for a wide range of conditions where the evidence for benefit is unequivocal. Of course inevitably that leaves us with a large grey middle ground where benefits are uncertain, particularly when trying to predict the outcome for one individual.

Any workable interpretation of an individual’s need for healthcare seems to demand we consider this concept of the ability to benefit. Of course government cash-limits the NHS and so as tax payers we might also reasonably expect that we should get some value for money in the way in which resources are distributed. In this way we move from a founding pledge based on need to a discussion based on cost-benefit and cost-effectiveness.

So what value should the NHS place on a year of your life? Well roughly speaking its £30,000 for one year of life spent in full health – that is the approximate level at which the National Institute for Health and Clinical Excellence (NICE) draws the line to decide what treatments are cost effective and therefore should be made available in the NHS.  So a new cancer drug which on average extends life for 6 months (but at less than full health) and costs £17,500 per patient would fail that test. In the years ahead with zero growth in the NHS in real terms, the discussion will have to move on from cost-effectiveness to one of affordability – in effect can we afford £30,000 per year of healthy life or must the NHS restrict access to healthcare to a lower threshold. You can have any treatment you need – just as long as we can afford it.

“When I use a word” Humpty Dumpty said, “…it means just what I choose it to mean—neither more nor less.”

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