Since you have done an excellent job in demonstrating the limitations of such survey data and any subsequent conclusions, you have also stymied your own arguments suggesting that the data demonstrate that the majority of respondents would not pay for your two examples:

“One way or another, only 22% of respondents, in total, indicated that they would be willing to put up the kind of money necessary to pay for a course of either cetuximab or Avastin as a top-up.”

Moreover, if the question was framed differently, the results might also differ. For example a more accurate representation might be given by the question:

‘If you were suffering from a terminal illness where there were no further treatment options, but then you were offered a new treatment for £17000 which MAY extend your life, would you be willing to pay?’

That is, after all, the question faced by these patients, rather than asking them for some arbitrary maximum valuation of an extended life.

With respect to the issue of co-payments, it has been neglected so far in this debate that this already exists within the NHS. Dentists can offer upgrades to NHS patients, not to mention that out-patient prescriptions are already paid for (in part) by the patient. A doctor is unlikely to refuse to assess the progress of a patient with a seriously broken-leg just because they have decided to invest in private physiotherapy. It seems the issue is largely over inpatient treatment.

State healthcare provision is analogous to state education provision: both provide a positive externality and ensure a minimum standard for all. Of course, private schools exist which might offer a (subjectively) better education if one is willing to pay but the same could be said of private hospitals. In education, a pupil can benefit from outside tuition without all state education being withdrawn, and in fact this would be positively encouraged.

As noted above, the current system allows for a patient to access drugs through a clinical trial. However, after phase I, trials are narrowed down for particular types of cancer. It may well be that a particular drug might be tested for efficacy in say head-and-neck cancers in the UK but for breast cancers only in the US. A UK breast cancer sufferer can not access the (licensed) drug through a trial without moving to the US and funding the entire cost, and cannot access it off trial (subject to satisfactory safety data) without paying the entire cost of their care.

A satisfactory outcome could perhaps be achieved by cancer charities in these cases, and if all parties were willing to be flexible then there is potential gain for all. If some of the leading charities set up a scheme matching up willing participants to other patients with the same cancer type in similar circumstances, they could form a group on whose behalf the charity could lobby the relevant pharmaceutical company to replicate a US (or other) trial at one of the excellent trial centres in the UK (so there would be a clear rationale for undertaking the trial). Any trial proposition without any rationale for study would be rejected out of hand as it would not be advantageous for the pharmaceutical company to run it, and so patients would not be ‘missold’ the product (indeed they would be entirely aware of what they are buying – a chance but nothing more). The trial participants could pay the cost of the drug itself (as they are arguing for the right to do so now). As a result, the drugs company would be able to collect double the data on the efficacy of the drug, whilst achieving lower trial costs (since some of the cost is borne by the patient). Equally, the patient would gain the right to pay just for the extra drug they desire. As an extra advantage, the NHS pays nothing and as such does not get itself into a mess over what it will and will not fund. This solution would further ease the concerns of those who fear that allowing this on the NHS would be hijacked by those with the intention of pushing for an insurance-based system. In effect the charities could facilitate a pact between a group of patients and a pharmaceutical company to the benefit of all, which is consistent with current rules on NHS co-payments. It is important to note that this is probably only possible for phase II trials, since it would be immoral for patients to pay thousands for a trial in which they may receive a placebo.

I know it is a little out of left field and i’m certain there are gaping holes in my argument which I would be glad to have pointed out. But it’s an idea…any thoughts?

Apologies for the verbiage – I have not mastered the knack of being concise.

I might just qualify that by noting that amongst the DE social group the view that the NHS should pay for everything may, in some cases, be predicated on necessity more than anything else.

When it comes to the 13% or so of ABs who took the same view then, yes, you absolutely have a point.

I think there is a still a fair distinction to be made between can’t pay and won’t pay.

Sadly, I fear that this group might not be wholly contiguous with the proportion of the public who actually don’t vote…

Overall, its pretty dysfunctional system no matter which angle you come at it from.

Good point.

if a doctor wishes to prescribe either of these drugs at the present time then the way to do it would be to find their patient a slot on a clinical effectiveness trial programme, where the tab would, of course, be picked up by the drug company that is looking to put these treatments into the market and not by the patient.

We do. The UK is one of the world leaders in clinical trials. However it is very frustrating when we participate in these studies, find a new drug is effective, and then are told that we can’t prescribe it.

Once a drug has passed the hurdle for licensing, which does demand strong evidence of efficacy and safety, the Pharma companies are not going to run more “effectiveness trials”-as far as they and the licensing authorities are concerned they have proved effectiveness, and each one of these trials costs tens of millions of dollars to run.

Of course much of the heat would be taken out of these arguments if NICE fulfilled its stated but so far totally unfulfilled promeise to assess drugs in parallel with the licensing process-then we would not have the limbo of 2 years knowing that a drug is effective but not if it passes the cost-effectiveness threshold.

You have not touched on drug companies’ pricing policies which is a whole new topic to discuss. Maybe another time

I think you are spot on about the spurious use of dodgy opinion polls-they probably share the same dodgy statisticians as the Prime Minister

I would be tempted to say the BMA, but I don’t have much faith in them after recent rulings. Far too self-serving.