John L. Marshall, MD; Bruce D. Cheson, MD; David Kerr, CBE, MD, DSc, FRCP, FMedSci


June 10, 2013

In This Article

Taking to the Barricades

Dr. Marshall: We live in a world of the third-party payer. It's not as if the individual patient is writing a check for these drugs. It's some other person. You, David, come from a world with the ultimate third-party payer, where decision-making is made on a national scale.

Dr. Kerr: Yes.

Dr. Marshall: We used to decry the methodology used by the National Institute for Health and Care Excellence (NICE) committee. Now, all of a sudden, it has become the hot way to do things. Could you talk a little bit about the culture in your world [United Kingdom] and drug decision-making around these high-cost medicines?

Dr. Kerr: There are a couple of points to pick up on. The first is what you mentioned about doctors as activists. Usually the way that we go about things is silently, in the halls of power, using influence to lobby. But there is a growing sense that doctors are "taking to the barricades." They are doing it through Blood.[1] They are doing it through articles in Oncology.[4,5] They are doing it through op-ed pieces in the New York Times.[6,7] Trotsky said, "It takes 3 people on a corner to start a revolution." This could be it.

There is a sense that doctors are standing out. They are doing it in a different way. This may come back to Trotsky's idea and make me sound left-wing. (I see you moving away from me.) But within socialized healthcare in the National Health Service (NHS), I was involved with Alan Milburn, who was our Health Secretary. As I become older, I'm becoming more of a public health doc, and I'm starting to understand why, if you make honest, open, transparent decisions about whether we, as a society, can afford these drugs, it is much better than just not talking about it.

It's much better than rationing (a terrible word) by the back door or rationing through silence or rationing by excluding large elements of the population. NICE was set up to be equitable. When I was a kid, the administrative units of the NHS were set up so that if you and I lived on opposite sides of the same street, my health unit might say, "Yes, you can get imatinib." But on your side of the street, no, you could not. It was post-code prescribing, a lottery of care. NICE was set up nationally to give us a framework that was open, understandable, and scalable; so if you feel you could afford $100,000 or $200,000 per quality-adjusted life-year, go for it. We think we can afford less than that. But perhaps if you are an Indian citizen, you can afford less still, and so on. I like it because it's open and honest. You can see the workings of the machine rather than just hearing, "I can't afford that one."


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