One of the basic expectations of a socialised health care system is the rationing of treatment and medicines so as to make both affordable to the largest number of people.However, one of the principal drawbacks of socialised care is that rationing also implies long delays in treatment and shortages of the most effective medicines.In the lingo of economists, there is a tradeoff between affordability for most patients and efficient care.In market-based health care systems, the reverse tradeoff is true, affordability is low for most patients, but effective care is high to those who can pay.
As a cancer patient living in the UK, I am trapped within the vagaries of the National Health Service (NHS), Britain’s socialised health care system.One of the benefits of being a cancer patient in the NHS is that the treatment (including operations) is free.Moreover, the quality of the treatment I have received is world class.On the other hand, the principal drawback has been the constant delays in treatment.These delays affect the timing of diagnoses, so Britain has one of the lowest cancer survivability rates in Europe on account of the delays in early detection of cancer.
Britain’s socialised health system also affects the rationing of drugs and medications.In the UK, the National Institute of Health Care Excellence (NICE) is the institution entrusted with making decisions on which drugs to administer throughout the NHS.NICE’s monstrous ethical task is to select the most cost effective drugs and treatment.The emphasis, though, appears to be on the cost, rather than on the effectiveness of the drugs.So there is a bias in favour of cheaper drugs, even though they may be less effective.Currently, within the cancer community in the UK, there is an intense debate about this particular tradeoff, namely in relation to a breast cancer drug called Kadcyla.This drug has been shown to extend life of advanced breast cancer patients by an average nine months, but it is also quite expensive (costing about £90,000 per year per patient).On the basis of cost-benefit analysis, NICE decided not to allow for this drug to be available to patients within the NHS system.
A closely related problem to the rationing of drugs is the emphasis on care to specific types of patients.When I first moved to the UK, one of the basic truisms of the NHS is that it is really good for children and for people who are dying.As a cancer patient, I now find myself closer to the second group.However, I have observed that within the group of people who are cancer patients, there appears to be an informal ranking.One broad group consists of people whose cancer has been detected early (stages 1 and 2) and who have a very high likelihood of surviving the illness.A second group consists of people with more advanced stages (stages 3 or 4) who have a probability of surviving. The third and final group consists of people who have advanced cancers and have little to no probability of surviving.Under a socialised health system, the emphasis appears to be on providing palliative care to those who are about to die, rather than curative care to those who have a higher probability of being cured.
So what is to be done?Are socialised health care systems inevitably trapped in a vicious circle of inefficiency and cost-savings?Well, economics offers a couple of solutions.In order to address the question of the cost-effectiveness of drugs, the state could provide some competition to private sector pharmaceutical companies.One of the first lessons of economics is that the state can provide goods at a cheaper price on the basis of economies of scale.The state could support the manufacture of cancer drugs at a cheaper price.
The other concern relates to the question of deciding whether to offer palliative care to terminally ill patients or curative care to those who can be cured.It appears to me obvious that the priority should be on curing those who can be cured, thus preventing them to get to the stage of terminal illness.This does not mean that terminally ill patients should be left to fend off for themselves.The priority for them should be in minimising pain and to allow for a dignified death.At present, the state criminalises most drugs, notably cannabis, that have a palliative effect in minimizing pain.Similarly, the state also criminalises assisted suicide. I understand the possible ethical concerns here, but given the option, I would certainly prefer to die at a time of my own choosing, rather than waiting for an uncertain time of death.
the one point I will just make though, only because someone explained it to me, is that this line that Kadcyla extends life by 9 months is misleading. Or should I say I find it misleading.
My friend J has been on her current regime for nearly 6 years and her graph showed that Kadcyla was estimated to extend her life for 9 months longer than the current drugs, lapatinib plus capecitabine, which are actually no longer available in any case.
you probably understood that, I didn't get it until she drew the graph
for the really simple minded, like me
at the beginning of her treatment for secondary breast cancer the combination of lapatinib plus capecitabine was potentially going to give her 3 to 4 years and the selling point for replacing lapatinib plus capecitabine with Kadcyla was that it would be a better drug because it would give her 3 to 4 years plus 9 months.
make sense ?
it's a rough guide, and as I said, the two drugs are still working 6 years later but when they stop she needs another drug and that would be Kadcyla.
and I agree with the assisted dying or dignity in dying points
