So how much should the world’s fifth largest economy pay toward drug development?

Depending upon exactly how you want to measure it the UK has around the fifth largest economy in the world. The creation of a new anti-cancer drug is of course a global (or at least rich world) public good. So, how much should that fifth richest society be asked to pay toward the creation of such a public good?

Too much apparently:

The health secretary, Jeremy Hunt, has been challenged by a coalition of cancer patients, clinicians and campaigners to effectively tear up the patent on a breast cancer drug that has been dropped from the NHS because of its cost and allow the import or manufacture of a cheap generic copy.

The radical demand is reminiscent of what happened with Aids drugs in the early 2000s. The cocktail of antiretroviral medicines that now keeps millions of people with HIV alive was unaffordable in the developing world until a legal loophole was found enabling generics companies in India to make cheap copies.

The drug, Kadcyla, known generically as T-DM1, will not be available to new patients with advanced breast cancer from November on the NHS, although those already on it will be able to continue getting it.

It has been turned down for NHS use by the National Institute for Health and Care Excellence (Nice). Recently NHS England dropped it from the list that the Cancer Drugs Fund – set up to pay for drugs Nice rejected – is willing to reimburse.

The drug offers some 6 extra months of life to those with a particular form of breast cancer resistant to other treatments.

But here’s the really important numbers. It costs some £70,000 for a course of it. It benefits perhaps 1,500 people a year. And the cost of development of a new anti-cancer drug is around and about $1 billion. That is, please do note, the cost of development. That doesn’t cover manufacturing costs, marketing, training and the rest. Further, the few drugs that make it out of the development process have to also pay for all the ones that fail within it. Finally, note that this isn’t about the profit driven nature of the industry. We can imagine alternative methods: say, governments pay for all drug development and testing. That wouldn’t change those numbers: someone, somewhere, still has to pay for those costs.

So, that fifth largest economy in the world is being asked to pay some £100 million a year (recall, that’s including all of the training, production, and marketing costs, not just the R&D) towards something that had an R&D cost of $1 billion.

Is that too much? Could be: but it doesn’t seem wildly out of order either. The effective life of a patent is really only around 10 years (because of the time it takes to get approval) so it certainly wouldn’t be appropriate for that fifth largest global economy to be paying £10 million a year for that global public good. Nor, obviously, £1 billion a year. So while there might be room to argue about this price it really doesn’t look wildly disproportionate.

What we’ve really got here, with this call for the patent to be broken and then we can have puppies for all, is the economic equivalent of baying at the Moon. Because drugs cost a great deal to develop. Therefore, if the drug only benefits a small number of people it will be expensive to administer to each of that small number. It’s simply a truism that a $1 billion cost amortised over few people has a high per capita cost. And that doesn’t change whatever the financing method used in that development.

Now we’ve won, let’s kill what works!

The victory of Jezzbollah and the Corbynistas appears to be turning politics in a French direction. That is, let’s not worry about whether something works of not, let’s check that it conforms with theory. And so it is with the various market reforms in the NHS. As Kristian Niemietz points out:

So when Corbyn used his acceptance speech to congratulate the Welsh government for ending the “internal market” in the Welsh NHS, declaring that this is “something we want to do in the rest of Britain”, he was not setting out a new policy stance – he was merely expressing a fait accompli. It was not Corbyn who exorcised the ghost of NHS reforms past. His party did that before he was even nominated.
Which is strange, because these reforms were a qualified success story.

Quite so, one of the things in recent years was that NHS England had rather more of that market reform than NHS Scotland or NHS Wales did. Entirely unsurprising to people like us NHS England also did rather better over those years than NHS Wales or NHS Scotland. But for Jezzbollah and fellow travellers markets are inefficient: so they must go, whether they worked or not:

The Scottish and the Welsh NHS are the closest thing to a counterfactual, because they are still more or less run like the old (and, if the Corbynistas get their way, the future) English NHS. Even though they are, in per capita terms, better funded and generally better staffed than their English counterpart, their performance lags on most measures. Rates of mortality amenable to healthcare are higher than in England, waiting times are longer, and hospital infections are more prevalent.

Niemietz has a fuller paper exploring the subject at that link.

It’s entirely possible for people to paint our own love of markets as being simply ideological. Enough people do that enough of the time that of course it’s possible. But our commitment to them is actually practical. We’re entirely happy to admit that there are times when competitive markets are not the solution. We do know our history and that time of competing private armies was called the Wars of the Roses and it’s not generally held to be a happy time. But we do support markets when they work.

As they do in the provision of health care to the populace. Those parts of the NHS system that have been flirting with markets provide more and better health care than those that don’t. We really do not see this as evidence that markets should be removed from the provision of health care. However French and conformant to theory our politics becomes.

Can we get this straight please? Obesity saves the NHS money

We have the public health crew on the rampage again:

Britain’s junk food diet has become the leading cause of death and ill-health, ahead of smoking, according to a study published in The Lancet.
The research shows that 40 per cent of NHS resources are spent dealing with ills caused by potentially preventable lifestyle factors such as unhealthy eating habits, obesity, alcohol and smoking.

We might think that since everyone pays for the NHS then everyone gets treated by the NHS. That fit person who survives to get dementia, that fattie that keels over at 40 are all deserving of the same treatment, no?

Overall, researchers found that life expectancy rose by 6.4 years between 1990 and 2013, increasing from 75.9 to 81.3 years.

And obviously something is going right. Leading to the thought that perhaps some of this is that as we don’t die of other things these days then lifestyle diseases are all that’s left to shuffle us off this mortal coil. But there’s a vast mistake in this analysis as well:

Simon Stevens, the head of the NHS, has said the health service could be bankrupted by the strain of weight-related disease if current trends are not reversed. One in five children is obese by the time they leave primary school, and two in three adults are overweight or obese.
In June, Mr Stevens said parents and society were doing something “terribly wrong” in how the next generation was being brought up, which would fuel a tide of diseases. He called for a change in the nation’s habits to turn around current trends.
“Cutting down on junk food diets, couch potato lifestyles, cigarettes and booze could make Britain one of the healthiest places to live in the world, while saving taxpayers billions on future NHS costs,” Mr Stevens said.

Someone who is the head of the NHS, someone responsible for spending £120 billion or so of our money, really should understand this following point. Fatties, boozers and gaspers save the NHS money, not cost it. We’ve mentioned this before around here:

The researchers found that from age 20 to 56, obese people racked up the most expensive health costs. But because both the smokers and the obese people died sooner than the healthy group, it cost less to treat them in the long run.

On average, healthy people lived 84 years. Smokers lived about 77 years and obese people lived about 80 years. Smokers and obese people tended to have more heart disease than the healthy people.

Cancer incidence, except for lung cancer, was the same in all three groups. Obese people had the most diabetes, and healthy people had the most strokes. Ultimately, the thin and healthy group cost the most, about $417,000, from age 20 on.

The cost of care for obese people was $371,000, and for smokers, about $326,000.

Here is a paper on that very point.

Having us all slim, svelte, sober and pure of lung into our 90s would cost the NHS very much more money than the current level of topers, smokers and lardbuckets does.

There might well be very good reasons to advise people that the private costs of their behaviour, the years of life they will lose through their habits, might well not be worth it. But the public costs of their actions are the other way around from what is being assumed here.

And really, we do think that someone in charge of £120 billion of our money should know the difference between a positive and negative sign in front of an influence upon his budget. That’s not, even in this day and age, too much to hope for, is it?

What good news as we face more First World Problems

This will no doubt set off the usual anguished whining among the usual suspects. But we regard this as cheering news, extremely cheering in fact:

Poor diet has emerged as the biggest contributor to early death around the world, according to new analysis from the leading authorities on the global disease, with red meat and sugar-sweetened beverages among the foods implicated in 21% of global deaths.

Smoking cigarettes still carries the highest risk factor of premature death in the UK, followed by high blood pressure and obesity. But the Institute of Health Metrics and Evaluation (IMHE) in the US says that a combination of dietary factors, from eating too few fruit and vegetables, nuts and whole grains to too much sodium and cholesterol, is taking a toll on health in the UK and across the globe.

We do rather doubt much of what we’re told by these prodnoses who would control our diet. It was only last week that they were telling us that animal fats would murder us all in our beds and then after decades of saying so they’ve changed their minds. However, the good news is here:

Sub-Saharan Africa has a different pattern of risks from the rest of the world, with a toxic combination of childhood undernutrition, unsafe water and sanitation, unsafe sex, and alcohol use.

That is, where people are still in that absolute destitution of peasant poverty then people die from simply lack of food and sanitation. Whereas where people are not in that absolute destitution of peasant poverty they live long enough to die of something else. We regard this as an advance in human civilisation, whatever our beliefs about the accuracy of the diagnoses of those First World diseases.

For it’s never going to be true that we can solve all the troubles of the world in one fell swoop: but that we do seem to be solving them, one by one, is reason for cheerfulness, no?

The Assisted Dying Bill should not have been euthanised

In light of the failure of the Assisted Dying Bill in the House of Commons today, I can’t help but wonder why people are so against the idea of legalising euthanasia. Nobody’s forcing you to die, so why should you be able to prevent other people from that choice?

Many of the main arguments include having respect for the sanctity of life, a fear that the vulnerable will come under pressure from family or friends to use the service, and suggestions that better palliative care could negate the need for euthanasia. However, while these are all valid arguments, I do not subscribe to the thought that any of these reasons override the principal of autonomy.

The government simply should not be able to tell another individual when they should or should not be allowed to die. The bill itself had a number of pretty solid proposals to prevent any potential abuse of the system, specifically the approval of two doctors and a high court judge. In Oregon, where assisted suicide is legal, about a third of people who were prescribed the drugs necessary then decided not to take them and extend their life, illustrating that people take comfort in just being able to have the choice, although they may not necessarily take it. To take the autonomy argument even further, there are a lot of people who believe the choice to die in a clinic should be available for all people and not just the terminally ill, as we ultimately should own ourselves.

Another reason beyond autonomy as to why this bill should have passed, is compassion for those who are suffering and in pain, or even just having the ability to decide the terms on which you die, surrounded by friends and loved ones. British people are the second most frequent visitors of Dignitas in Switzerland, so there is clearly demand for legal euthanasia within the UK, yet the government’s decision today has simply limited the ability of those who are less well off to make that decision. A trip to Dignitas can cost between €4,000 and €7,000, not including the cost of flights and accommodation for family members. That’s something many people in the UK are not financially able to do; the legalisation of euthanasia in the UK would have made this fundamentally humane practice more accessible for people of all income levels.

Although it is estimated 1 in 5 people allow family circumstances to influence their decision, there is no reason why a person should not be allowed in their own right to not want to burden their family. Scott Alexander found that euthanasia does not disproportionately affect the elderly and that 99.8% of Dutch euthanisations were in cases where the pain was said to be “unbearable”, clearly showing that family pressure is not a primary reason behind euthanasia. The court and doctor checks suggested by the UK bill were part of a process to ensure external pressure is therefore not a reason behind the patient’s decision. In addition, instances where euthanasia has been permitted for psychological reasons rather than terminal illness are minimal, with one case Belgium being the exception to this rule.

The percentage of deaths in Oregon caused by euthanasia last year was only 0.3%. The bill that failed today was not an act to encourage suicide or make it ‘the norm’, as it clearly is not in Oregon, but a logical and compassionate way to extend the freedoms of people in the UK. The government regulates enough already, the wishes of a terminally ill person should be one area free from their interference.