"NHS ban medicine if you are 'too old' in new attack on Britain's elderly" is the headline in the Daily Express, with many other news sources echoing similar dire warnings.
The media storm is based on the news that, as part of a consultation, the Department of Health has asked the National Institute for Health and Care Excellence (NICE) to take "wider societal benefits" into account when approving new drugs, as well as considering the burden of illness and the impact a disease has on patients.
There are fears that vulnerable groups, including the elderly, could lose out if they are judged not to contribute as much to society as other groups, especially if societal impact is just assessed from an economic viewpoint. The concern is that NICE may not recommend drugs specifically targeted at diseases that occur in these vulnerable groups.
But NICE chief executive Sir Andrew Dillon has been quoted as saying: "We have no intention of introducing a change to our methods that would disadvantage older people.
"It's not about how old or young you are when you get a disease or condition, it's about your capacity to benefit from the treatments that we're looking at. That's what's important.
"That's where we start and is at the core of the decision that we take on recommending new drugs to the NHS ... What we don't want to say is those 10 years you have between 70 and 80, although clearly you are not going to be working, are not going to be valuable to somebody. You might be doing all sorts of very useful things for your family or local society."
How does NICE currently assess whether a treatment represents value for money?
NICE measures how well drugs work by calculating how many "quality-adjusted life years" (QALYs) a drug provides. QALYs take into account how long a drug can extend a person's life, as well as the quality of that life. Quality of life considers the impact of disease-related symptoms and therapy-induced side effects, as well as pain, mobility and mood. This can range from below 0 (worst possible health) to 1 (best possible health).
QALYs are calculated by multiplying the extension to life by the quality of life. One QALY is equivalent to one year of perfect health, two years of 50% perfect health, or four years of 25% perfect health. It is calculated using the best available evidence on how well a drug works. Cost effectiveness is then assessed by calculating how much a drug costs per QALY. Each drug is considered on a case-by-case basis.
NICE uses this measure because it allows a direct comparison to be made between different drugs. This allows the organisation to make its decisions consistently, transparently and fairly.
However, decisions about whether certain interventions should be recommended are not based on the evidence of their relative costs and benefits alone. NICE considers other factors when developing its guidance, including the need to distribute health resources in the fairest way possible.
Does NICE take wider ethical concerns into account?
NICE subscribes to the widely accepted moral principles that underpin clinical and public health practice:
- respect for autonomy – this recognises the rights of individuals to make informed choices about healthcare, health promotion and health protection, and gives rise to the concept of patient choice and consent to treatment.
- non-maleficence and beneficence – this principle is arguably the oldest medical ethical principle in human history: primum non nocere, which is Latin for "first, do no harm". Clinicians should always seek to avoid harming patients and to benefit individuals as far as possible. Taken together, this means balancing the benefits and harms when deciding whether an intervention is appropriate.
- justice – this entails providing services in a fair and appropriate manner.
In healthcare there is often a mismatch between demands and resources, in that demand always outstrips supply. Consequently, there are broadly two approaches to help decide how to allocate limited healthcare resources:
- a utilitarian approach, which involves allocating resources to maximise the health of the community as a whole
- an egalitarian approach, which involves distributing healthcare resources to allow each individual to have a fair share of the opportunities available
NICE does not subscribe fully to either approach, and instead judges cases and situations on their individual merits. It concentrates on ensuring that the processes by which healthcare decisions are reached are transparent and that the reasons for the decisions are explicit.
The decisions that NICE makes and the reasons for them are made public and can be challenged and revised. The decision making process is also regulated.
NICE is bound by legislation on human rights, discrimination and equality. Assessing the impact of its guidance on equality is an integral part of the NICE guidance development process.
What is the proposed change?
The Department of Health asked NICE to include "wider societal benefits" as well as the burden of illness or the impact of a disease when it decides whether to recommend a drug for use in the NHS. This is in addition to considering a drug's cost and efficacy (how well it works).
These plans are only at a draft stage at the moment, and will soon be released for consultation.
How has NICE responded to the claims?
NICE has issued a "Behind the Headlines"-style critique of the story in The Daily Telegraph. They state that The Telegraph is wrong to speculate that the proposed changes will result in older patients missing out on treatments because the elderly are considered to not contribute as much to society as younger people.
The riposte features quotes from Sir Andrew Dillon, chief executive of NICE, who states that the organisation has "no intention of introducing a change to our methods that would disadvantage older people".
The Department of Health has said that the media reporting "is irresponsible scaremongering based on pure speculation about a consultation that has not even started. It is absolutely not true to say that older people will not get treatment because of their age".