Fifty years ago, Britains state-funded National Health Service was heralded as a triumph for the social ideal that people should be treated according to medical need rather than the ability to pay. Britons were brought up to believe the NHS was the envy of the world and that health care needs would fall as general health improved. No one anticipated the cruel paradox that every advance in health care generates another bill, and there have been more advances in the last 50 years than in the previous 2000.
This is why Britain, with one of the worlds largest economies, has struggled harder than most developed countries to reconcile finite resources with seemingly infinite demand. It now has one of the highest age-standardized cancer mortality rates. But leading British specialists are opposed to any idea that Britain should try and match U.S. spending. The United States spent about seven times more per head of population on chemotherapy in 1997 than the United Kingdom£7.76 (about US $11.70) compared with £0.95 (US $1.40). This compares with £1.29 (US $1.95) in France, £3.31 (US $5.00) in Italy, and £6.24 (US $9.40) in Germany.
But British specialists do want to correct spending imbalances. Cancer affects 35% of the U.K. population and accounts for 25% of all deaths, but total expenditure on all cancer care accounts for only 7% of the NHS budget.
In a new report, The Prescribing of Costly Medicines, the Royal College of Physicians estimates that fewer than 5% of U.K. patients with non-small cell lung cancer receive chemotherapy. This was "probably reasonable," the report says, until randomized control trials showed improvements in survival, relief from tumor-related symptoms, and improvements in quality of life.
The report adds: "These days positive results arising from trials of chemotherapy are disseminated very rapidly and widely, and become quickly known to patients and patient advocacy groups." But current funding arrangements prevent "speedy clinical implementation of positive trial results."
Bringing the NHS budget for chemotherapy into line with the internationally accepted standard of practice would require a two- to threefold increase in budget allocation. Why has the United Kingdom fallen so far behind its European neighbors and the United States? Why hasnt it adjusted to the economic demands of the therapeutic revolution? The answer lies in the different sources of health care expenditure and political ideology.
State spending on health care is much the same throughout Western Europe: the difference between the United Kingdom and its European cousins lies in private sector expenditures. The United Kingdom contributes some 5.8% of its gross domestic product to the cost of health care from taxation, but only about 1.1% from private income. In comparison, the average private contribution to health care costs in other European countries is 7.7%.
Until very recently any idea that a Labor government should establish an alliance with the private health care sector was an anathemabut no more. But how much should Britain spend on the NHS and on cancer therapy? Should the oncology community be campaigning for a sevenfold increase to put Britain on the same footing as the United States?
Not according to Nick Thatcher M.D., Ph.D., of the Department of Medical Oncology, The Christie Hospital, Manchester. Health spending policy, he believes, is a reflection of different cultures and different expectations.
"In the U.S.A., people will not accept theres no effective treatment," he said. "Theyll go around and find a private oncologist whos prepared to treat them. In the U.K., the reverse is true. Were not so aggressive. I would argue that were not aggressive enough, but that we shouldnt be as aggressive as the U.S.A., where all treatment is perceived to be good treatment.
"Its all a question of balance. The oncology community has suggested it would be reasonable to increase the total spending on chemotherapy four- to fivefoldto about £4 per head."
Thatcher, a member of the working party that produced the Royal College report, believes the quality of life debate has had an adverse effect on cancer funding. "People used to think that chemotherapy caused the most horrific side effects for no benefit. Chemotherapy was used by non-oncologists in what Id call an uncontrolled manner. This led to the idea that it was highly dangerous and had no benefit. Whats really important in chemotherapy is that the patient have the protection of a proper team around themoncologists and specialist nurses." But Britain, population 56 million, has only 100 oncologists.
David Kerr, M.D., Ph.D., professor of oncology at the University of Birmingham, England, is one of the leading lights in a new campaign to increase NHS cancer spending. The Campaign for Effective and Rational Treatment led to a recent "cancer summit" chaired by Prime Minister Tony Blair.
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He may be right. Extensive media coverage has put the government under pressure to do more for cancer patients, including correcting spending imbalances. In the 12 months to January 1998, the NHS spent £68 million (US $102.6 million) on chemotherapy, compared with £754 million (US $1.1 billion) on anti-hypertensives; £602 million (US $908 million) on ulcer-healing agents; and £420 million (US $634 million) on antibiotics.
Very few Britons still believe the NHS is the envy of the world. This may be its salvation. Patients are no longer prepared, as they once were, to abdicate responsibility for health care to the NHS and the medical profession. Debate about the state of the NHS used to be restricted largely to the medical professiononce the most privately critical and publicly silent of organizations. But now bodies like the Royal College are encouraging the public "to take part in decisions that affect their vital interests."
(This is the first of a two-part series. Part two will look at the emergence of "patient power" in Britain.)
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