What would help the NHS?

[Pebble]

There isn't a conspiracy because the drug companies do not have any intention of depriving people of cures or treatments. The overriding constraint is that it should be profitable and they cannot afford in competition terms to divert investment resources into products which are not the most profitable. They are not conspiring with anyone, simply pursuing their own commercial interests against other capitalist companies.

So it's not intentional, and it's not a conspiracy - it's the result of the coercive logic of capitalist competition. It's just a very sub-optimal outcome of market capitalism applied to health.

I won't lose any sleep over the conspiracy point - you may take that point as won. The reason I use the term is that they claim to have the patients best interest at heart, but the system they operate under means we know and they know this is not so.

However, that does not address my main point - is there any evidence that the pragmatic solution - capitalism, is directly/indirectly preventing useful research?
Failing to support blue skies projects is not the same thing - that is what universities and mavericks are for.

[Bob Lloyd]

I won't lose any sleep over the conspiracy point - you may take that point as won. The reason I use the term is that they claim to have the patients best interest at heart, but the system they operate under means we know and they know this is not so.

However, that does not address my main point - is there any evidence that the pragmatic solution - capitalism, is directly/indirectly preventing useful research?
Failing to support blue skies projects is not the same thing - that is what universities and mavericks are for.

Of course their research is useful because it is directed to a product that addresses a market. The question for me has always been the level of commercial secrecy, the wasted repetition of research, the filtering away the less profitable approaches, the restriction of patents, the exploitation of monopoly pricing, and so on. You could say that all of these restrict the available resources for other useful research thereby reducing the overall delivery of social benefit.

Is blue sky projects really a disparaging term for investigating those possible solutions that aren't commercially profitable? Or does it mean those with a lower probability of success? The latter raises another interesting contrast between what would constitute the social good, and would be a practical product, i.e. commercially profitable. Cutting out unnecessary repeated dead-end research would provide funds for exploration of just those possible solutions ruled out on commercial grounds.

Thanks for the very interesting discussion. I might have to leave it now for a while. Hasta luego.

[Jin_Shei]

... the Govt who have ultimate control of the NHS....

What might happen if the NHS wasn't changed with every government?

I have worked in it for around fifteen years, for the same people in the same area and worked for four differently named and organised front line services. Each time it changes, it costs money to rebrand, to reorganise and it takes time to settle and work out problems. Then someone changes us again.

Is change always useful and positive?

[Harryprice]

What might happen if the NHS wasn't changed with every government?

I have worked in it for around fifteen years, for the same people in the same area and worked for four differently named and organised front line services. Each time it changes, it costs money to rebrand, to reorganise and it takes time to settle and work out problems. Then someone changes us again.

Would you say it works well and is good value for money?

[Pebble]

Would you say it works well and is good value for money?

The problem with healthcare is the definition of value for money. If you go on QALYs as NICE does, then anything that within the published RCTs that gives a QALY for less than £20,000 is value for money. Since pharma know this, the trick is to price such that the available data justifies this. Now if there is no proven therapy one can use placebo as the comparator - so for example spironolactone is dirt cheap, and proven in stable heart failure, but it had not been specificaly proven in post myocardial infarction heart failure - so eplerenone (expensive) was trialled in that sub group and is now the recommended therapy. Anyone can see that this is just manouvering - but it is value for money. The approach also supports an add on approach to therapies - since all trials must be conducted on optimal background therapy - always adding never taking away - so post MI 6 tablets automatically appear - all value for money.
Next QALY is rarely assessed formally in any of the trials - so surrogates of questionable relevance are used instead.

But if you want value for money - there is no substitute. The same concepts are now used to determine the value of 'caring' what is the cost of delivery, how much are the QALYs improved when compared to a cheaper less caring approach? Given how inaccurate QALYs are it is easy to bias the findings toward cheaper is better here.

As for gross comparisons, for some what less investment, the UK system now gives equivalent outcomes to most European services (cancer and device implantation rates may be notable exceptions - but unclear that this is not simply a time lag phenomenon in the former case, and just good practice in the latter) - only the French system seems preferred by patients (but rather more expensive).

[Jin_Shei]

Would you say it works well and is good value for money?

I'd say it is as variable as any huge company that has constant change. There are bits of it that work well, where waste is minimal, and bits where there is visible waste.

Don't get me wrong, I'm a big fan on the ethos of the NHS, and I think we could do better. But rapid change with no evidence base for the decisions is not something I'm a fan of.