Ship of Fools: £250.000+ for one or for many

Thread: £250.000+ for one or for many Board: Purgatory / Ship of Fools.

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Posted by aamcle (# 13125) on :

I'm looking to clear up a moral or maybe ethical dilemma that's troubling me but to which I can not find a clear solution.

The background:-

On this day and at this time there is £XXXXXXXXX available for health and social care and that is apparently 4 billion less than the health care establishment say they need.

As a result there are shortages of resources, at some future time there may be more or sadly even less.

At this point I must plead with anybody who's good enough to help me with this not to jump into the alternate reality inhabited by those who write for the Guardian.

The budget is what is is today, so no comments like; it should be more, it's immoral and so on, it is what it is and that is the bottom line.

A young man with multiple issues but apparently not in pain or in immanent danger of death is being looked after at a cost to the health/social services of £250,000 and that's just for day care the total could be much more. It's something I saw on TV so he is real.

With limited resources (see above) is it right that £250,000+ is pored into one person, or used for the benefit of many?

I know that individually he represents a tiny fraction of the budget but that's not the point and there are of course many many examples of vastly expensive care/health costs.

But Granny needs a new hip it hurts!, a young Mum with cancer and an improbable number of kids needs drugs...add as many as you want.

I'd appreciate your thoughts on this but please please keep it on track.

We have the budget we have, not the one we want, money can only be spent once and comments like; it's so wrong, we should do more and so don't actually answer the question.

God Bless. aamcle

Posted by mr cheesy (# 3330) on :

quote:
Originally posted by aamcle:

With limited resources (see above) is it right that £250,000+ is pored into one person, or used for the benefit of many?

It's an incredibly difficult thing to talk about. Obviously it is also something which goes on daily in various medical contexts around the world, and might be said to be a form of triage.

I think on the one hand, the medics and paramedics are probably best placed to make this kind of decision - but then on the other hand, arguably others should be contributing to the difficult ethical conversations about how to make decisions between different treatments and between the needs of different patients.

On some level presumably there has to be some fairly hard-nosed discussion about the benefits to the patient. £250,000 on an artificial limb for a child is perhaps a different calculation than £250,000 for a cancer medication which will only keep an elderly patient alive for a few months.

But other than those general thoughts, I'm not sure there are going to be many here with the expertise to answer your question.

It's difficult.

Posted by Galilit (# 16470) on :

Living on our kibbutz we had a severely autistic child ((born 1981) and we poured zillions into him.
He eventually he went to a fully residential facility where we still support him. I think he has some state support these days but back then those benefits were not set up yet.
No questions asked - everyone thought "If he was mine I would want the kibbutz to support him"

Posted by BroJames (# 9636) on :

At your request, parking the question of the inadequate current budget for the NHS, there are still some challenges about addressing the issues that remain. A finite budget means that some needs will not be met or hopes realised.

Some treatments are very expensive - this issue has particularly been raised in relation to cancer drugs that extend life but do not cure. Similarly,continuous care for an individual is very expensive. (Although your post mixes two separate strands of funding - NHS and social care.)

In the UK some of the decision making is done by NICE which evaluates treatments and, for example, has set a 'normal' threshold for a treatment that it should not cost more than £20,000-£30,000 per Quality Adjusted Life Year. The conundrum remains, however, because the money spent on that treatment would probably fund four or five hip replacements. How do you balance those things?

Posted by Bishops Finger (# 5430) on :

Just for clarification - over what period of time is the young man costing £250000? Given the price of day care, I think perhaps not that long.

On a personal note, I'm dependent now on a regular dose of a certain medication (not that common - I'm the only patient at my local GP and pharmacy to need it).

A month's prescription is £200 or thereabouts, depending on the source, so I cost the NHS about £2400 per annum for this one medication alone - I'm taking several more, one of which is an anti-epileptic drug, so quite important, but I'm not sure of the price of them.

I'm 66, and my life expectancy is 5-10 years, so the NHS may well pay more than £24000 to keep me going. Am I (and others like me) worth it? If they should, unhappily, pull the plug on me, I would fairly quickly (within a few hours) go into a coma, and die.

Tricky, indeed.

IJ

Posted by quetzalcoatl (# 16740) on :

I was wondering what Nice limits are - I read that their limit on drugs is £30,000 per year, and £50, 000 for end of life treatments. I also read about an upper limit of £300, 000 per QALY (quality adjusted life year), for 'very rare conditions'.

I have no idea how these figures are arrived at, but no doubt, it is done conscientiously and transparently, and I would hate to have to do it. I suppose you can always argue that that amount of money would pay for x number of hip operations or whatever, but it's a hard argument to make.

https://www.nice.org.uk/news/article/nice-gets-go-ahead-to-fast-track-more-drug-approvals

Posted by aamcle (# 13125) on :

The actual sums involved are at least to me less important than the principal.

So Yes or No.

aamcle

Posted by Bishops Finger (# 5430) on :

Yes, or No, to what question, exactly?

Unfortunately, £££ come into it, whether we like it or not.

As someone once said, seeing someone else objecting to money being wasted, 'For you always have the poor with you....'.

IJ

Posted by mr cheesy (# 3330) on :

quote:
Originally posted by aamcle:
The actual sums involved are at least to me less important than the principal.

So Yes or No.

aamcle

What principle?

What actually are you asking?

Posted by Marvin the Martian (# 4360) on :

quote:
Originally posted by mr cheesy:
What actually are you asking?

"Do the needs of the many outweigh the needs of the one", essentially.

Posted by aamcle (# 13125) on :

If there are not enough resources to meet all needs, is it right to spend hugely on one or help more who have needs?

Live long and Prosper.

aamcle

Posted by Bishops Finger (# 5430) on :

I don't think that's a question that can be answered at all, let alone with a simplistic 'Yes' or 'No'.

There will always be cases which appear to be more pressing than others, but each individual's circumstances will differ from another's.

YMMV.

IJ

Posted by Jengie jon (# 273) on :

aamcle

May we include the defence budget in this?

Jengie

Posted by Bishops Finger (# 5430) on :

Ouch!

Good question, IMHO. Once again, simplistic answers are just Not Available.

[Help]

Posted by aamcle (# 13125) on :

Sorry the answer is binary, you spend or you don't you spend on one or more than one.

aamcle

Posted by Bishops Finger (# 5430) on :

Sorry, I think you might need to rephrase that, as, frankly, I don't understand it.

Life - and health - are not binary.

IJ

Posted by mr cheesy (# 3330) on :

quote:
Originally posted by aamcle:
Sorry the answer is binary, you spend or you don't you spend on one or more than one.

aamcle

No, it really isn't binary.

There are 65 million people in the UK. Spreading the spending on this individual to the maximum number of people would be less than 1p each. Which is clearly an unhelpful amount to spend on everyone's healthcare.

It simply isn't a simple calculation. And I don't want to talk about individuals (a) because that's not fair and (b) because few or none of us here have the expertise to know how these decisions are made.

Posted by mr cheesy (# 3330) on :

quote:
Originally posted by Bishops Finger:
Sorry, I think you might need to rephrase that, as, frankly, I don't understand it.

Life - and health - are not binary.

IJ

I suppose one could take the total NHS budget, divide it by the number of people in the country and then say that this is the maximum that can ethically be spent on any individual.

That's about £125 billion. So I suppose that works out at about £2000 each.

But that's a pretty ridiculous way to arrange a health system. Even an insurance based system isn't going to determine that an individual costs too much in this way.

Posted by Ricardus (# 8757) on :

Surely it isn't zero-sum, though, because the money is budgeted for a particular treatment rather than a particular person, and therefore everyone in the country benefits insofar as they have the assurance that they will get that treatment if they need it.

So even if in practice only one person in the country ever receives the £250,000 treatment, everyone else knows they don't have to stash away £250,000 against the possibility that they might need it.

Posted by mr cheesy (# 3330) on :

aamcle, are you asking for a school assignment?

Posted by Curiosity killed ... (# 11770) on :

Isn't this along the lines of the trolley ethical discussions? Also available as the Philospher's Arms podcast on trolleyology where the discussion is expanded to include spending on health.

Posted by Boogie (# 13538) on :

It is simple imo.

Put up taxes and ring fence the amount for the NHS.

Whatever it takes, it’s worth it.

Posted by Bishops Finger (# 5430) on :

From the OP:

quote:
At this point I must plead with anybody who's good enough to help me with this not to jump into the alternate reality inhabited by those who write for the Guardian.

Asking a question, and at the same time rubbishing those who might have a valid view about it, is not the way to go.

Is there an anti-liberal campaign brewing up here?

[Paranoid]

Posted by BroJames (# 9636) on :

I just think there is not a simple *general* yes or no answer to this. How can you balance life-saving heart surgery, say, for one against hip replacements for many for the same price?

You cited an example of day care for someone, but you didn’t say what would happen if that was withdrawn.

The underlying idea when the NHS was established was that people would get the medical care they needed free at the point of use. Politically there is now an ongoing debate in the UK about what are the limits of affordability, but it isn’t just a question of how many people are helped, it is also a question of how serious the impact of the illness or condition is.

Posted by aamcle (# 13125) on :

quote:
Originally posted by Bishops Finger:
Sorry, I think you might need to rephrase that, as, frankly, I don't understand it.

Life - and health - are not binary.

IJ

Err.. you are alive or you are dead it doesn't get more binary.

aamcle

Posted by Bishops Finger (# 5430) on :

Rubbish.

If you're dead, you're dead (but, hopefully, in Heaven - TIACW, after all).

There are many ways of being 'alive', and this may mean suffering in one way or another.

Please explain exactly what the question is to which you are seeking a 'Yes' or 'No' answer.

IJ

Posted by aamcle (# 13125) on :

I missed a bit

quote:
Asking a question, and at the same time rubbishing those who might have a valid view about it, is not the way to go.

Is there an anti-liberal campaign brewing up here?

1, I was asking about specifics or at least that was the plan and trying to keep people on subject rather than have them wander off. Might I ask have you read the Guardian?

2, Anytime I'm no liberal. My personal politics are socialist, not internationalist and not apologetic. My beliefs are more or less traditional although not High Church.

aamcle

Posted by aamcle (# 13125) on :

quote:

Please explain exactly what the question is to which you are seeking a 'Yes' or 'No' answer.

It was in the original post, but again and for the last time. However I'll re-phrase it in case it wasn't clear.

Is it right to spend a vast sum of money on one persons health/social care when that spend will adversely, possibly fatality effect the well being of several others?

Or for any Trekkers, do the needs of the many out way the need of the few?

aamcle

[ 29. November 2017, 20:46: Message edited by: aamcle ]

Posted by Bishops Finger (# 5430) on :

Possibly.

YMMV.

IJ

Posted by mark_in_manchester (# 15978) on :

We're trying to help you sort the problems out with your question.

If you spend it on two other people, they get 125k each. But isn't that still rather a lot? maybe we should spend it on four - 62.5k for all. That still sounds like too much, so what could we do for eight?

And you end up spending a penny on everyone, which buys them nothing.

I'm an engineer. Thinking like an engineer, you're right, this is an optimisation problem where the right amount of money per patient is somewhere between zero and infinity. Now choose your constraints and go forth and optimise.

Posted by Bishops Finger (# 5430) on :

Possibly.

YMMV.

IJ

That is an answer to both questions, BTW.

Posted by aamcle (# 13125) on :

What can I say?

When your right your right.

And henceforth I shall go forth and optimise.

I may as well cause I'm no closer to an answer, Oh well it's nearly time for bed.

aamcle

[ 29. November 2017, 21:00: Message edited by: aamcle ]

Posted by Bishops Finger (# 5430) on :

It's good to know that Common Sense does, occasionally, prevail.

IJ

Posted by orfeo (# 13878) on :

quote:
Originally posted by aamcle:
With limited resources (see above) is it right that £250,000+ is pored into one person, or used for the benefit of many?

You can't reasonably expect an answer to an equation you've only provided one half of. Who are these "many"? What, exactly, are their needs?

quote:
I know that individually he represents a tiny fraction of the budget but that's not the point

Well it should be the point. Zeroing in on one tiny fraction of the whole is likely to severely distort the situation, much as it does in copyright cases where 1 song is declared to have copied another on the basis of a sequence of six notes.

It's a bit like looking at one dot on a pontillist painting and declaring that you don't like the artwork because the dot is brown, and you don't like the colour brown.

Posted by aamcle (# 13125) on :

quote:
Who are these "many"? What, exactly, are their needs?

Oh dear one of the common debate busters techniques.

Would you like me to collect the names of the people who were stuck in corridors on trolleys last winter? Think back to the news programs.

If you like I'll ask my wife a recently retired district nurse to list the horrors she's seen horrors brought on by lack of resources.

Get real, go read a news paper yes even the Guardian and you will find many many stories of tragedy

Posted by Bishops Finger (# 5430) on :

Emotional blackmail does not help your case, as I'm sure many of us in the UK are aware of the shortcomings of the NHS (I'm a retired ambulance-person, so I, too, have seen sights I'd rather not have seen).

The point some of us are trying to make is that it is not as easy a problem to solve as you seem to think.

IJ

Posted by Adeodatus (# 4992) on :

This is a common sort of exercise in the teaching of medical ethics. The first point to make - and often the most difficult to get across - is that all considerations like "sweet little old lady", "busy mum of five", or "hopeless criminal wastrel" don't come into the equation at all - or if they do, they're so far down the list they're practically invisible. Medical help is available to all, regardless of any moral judgement we might make of the circumstances or quality of their life.

There are a number of other medical-ethical considerations, but broadly speaking, medical intervention is done according to perceived clinical need. So, for example, X's cardiac arrest will always be treated ahead of Y's ingrowing toenail, regardless of any other consideration, including the relatively high cost. The generalised form of the question, therefore, is about the prioritising of clinical need. This is incredibly complicated, there are endless arguments about it, but in the UK at least, some of the decision-making is devolved onto the National Institute for Health & Care Excellence (NICE for short - "Health" was a late intrusion into the title and spoiled the acronym).

I'm aware that I may appear to have dodged the question, but really what I've said so far is that the question, having been argued about for decades if not centuries, has been to some extent institutionalised.

There is, however, one further point that may be useful. Once you've begun a course of treatment, you're on very wobbly ethical ground if you want to stop it. Obviously the patient can stop the treatment any time they like (provided they have the mental capacity to make that decision). But if you're a doctor, generally speaking, you can only stop a treatment if it has ceased to have any benefit to the patient, or if the harm it does to the patient has begun to outweigh the benefit. You cannot say, "Sorry, the money's run out". If that means a hundred hip replacements get postponed then sorry, but it is highly unethical to end a beneficial treatment under almost any circumstances. (I honestly can't think of circumstances where it would even be considered.)

Posted by hatless (# 3365) on :

The following Star Trek film had it that the needs of the one outweigh the needs of the many. Throwing extravagant resources at one person affirms the value of all human lives. If a coldly utilitarian calculation underlies everything we do, then the world is a grey place indeed.

Posted by orfeo (# 13878) on :

quote:
Originally posted by aamcle:

quote:
Who are these "many"? What, exactly, are their needs?
Oh dear one of the common debate busters techniques.

Would you like me to collect the names of the people who were stuck in corridors on trolleys last winter? Think back to the news programs.

If you like I'll ask my wife a recently retired district nurse to list the horrors she's seen horrors brought on by lack of resources.

Get real, go read a news paper yes even the Guardian and you will find many many stories of tragedy

I don’t think allocation of resources works in the way you think it does. The point is not that I want you to collect a series of anecdotes, the point is that these kinds of decisions are made on big aggregates of data and trends. Nobody makes a decision about how much funding should be available for a particular kind of treatment by doing a head-count in the local hospital and taking names.

Posted by Ricardus (# 8757) on :

Also, surely when a patient can't get access to a £2,000 NHS treatment, the reason isn't usually as simple as 'because the money has gone to pay for a £250,000 treatment'.

If a patient is on a trolley in a corridor, the problem isn't that the money isn't available for their treatment, the problem is more likely to be caused by all the various organisational issues that lead to delayed discharge of other patients.

Posted by aamcle (# 13125) on :

I'm going to conclude that there is no answer within my reach.

Instinctively I feel there is a line or limit, but I'm too limited to find it.

aamcle

Posted by Leorning Cniht (# 17564) on :

quote:
Originally posted by aamcle:
The actual sums involved are at least to me less important than the principal.

So Yes or No.

The principle is clear, and is the basis if the clinical decisions made by NICE that have been referred to earlier. We explicitly choose not to spend large sums of money on treatments which offer only marginal benefit, because the benefits are not worth the cost. That's what QALYs do for you.

The application of that principle to the particular case you cite is not so clear. The young man who apparently requires a quarter million of care (and before we get too deep in the numbers, we'll have to audit that to check that we're comparing apples and apples) could be any number of young people with a combination of mental and physical disabilities. They are reasonably healthy, not in any immediate danger of death, and utterly incapable of living independently.

Should we care for people like that rather than just abandoning them? Yes, of course.

Posted by Bishops Finger (# 5430) on :

aamcle said:

quote:
I'm going to conclude that there is no answer within my reach.

QED.

IJ

Posted by Russ (# 120) on :

Is anyone arguing against the QALY approach or is it agreed that that's the answer ?

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