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THE COST OF HIGH-TECHNOLOGY MEDICINE
371
THE COST OF HIGH-TECHNOLOGY MEDICINE SiR,-Dr Golding and Mr Tosey (July 26, p. 195) address an important question in their paper but do not discuss a number of equally important wider issues which might influence their conclusions. They also perpetuate the catchphrase of "new and expensive forms of high-technology medicine". All hospital medicine is high-cost; and salaries, not machines, account for three-quarters of the expense. Equally, "high-technology" medicine includes the development of vaccines and drugs which may bring about cheap treatment, or better still prevention. The difference between "modern high-technology" medicine and traditional hospital practice is that the former has usually been evaluated carefully, in terms of both fixed and variable costs on the one hand and survival and rehabilitation on the other. Older procedures have rarely, if ever, been subjected to similar cost-benefit analysis. Why should it be only new treatments which must be evaluated by controlled trials before they are introduced as Golding and Tosey suggest? Why not start by costing and evaluating the effect of any number of "established" treatments whose cost is high and whose value is, to say the least, in question?’ Each reader can, I am sure, supply his or her own list from their own field of practice without dif-
ficulty.
-
The myth that it is only technologically oriented medicine which is expensive dies hard. For example, the paper includes costings from the King’s group on dialysis and transplantation for end-stage renal failure, a condition fatal within days or weeks at most. (In passing, one notes that their costs of both home and centre dialysis are higher, and the costs of transplantation lower, than estimates arrived at by other authors.2 Also, the very small costs of transplantation after the first year are not brought out.) For comparison, the cost at 1980 prices of long-stay geriatric care is z7500 per year per patient, and care of long-stay mental handicap patients C6200 per year per patient. These costs are similar to keeping someone in prison (5900 per annum; or [,12 100 fbrahigh-securityprisoner[1979 prices]).4 All these figures are within the same range as keeping a patient in renal failure not only alive on dialysis but, in threequarters of all those treated, at work producing income.5 Transplantation is cheaper than any of the examples cited. The authors rightly point out that one cannot judge "benefit" in terms of economic return alone; if this were so then (for example) all hospice care should cease forthwith. Yet, when the grounds for curtailing life-saving treatment such as dialysis and transplantationare considered, these are precisely the grounds upon which (for example) the failure to treat patients over the age of 60 with renal failure is justified. The authors remark that it is "less acceptable" to restrict a proven technique such as dialysis and renal transplantation; this is untrue-it is unacceptable and has been found so in all other developed Western countries.5 Nevertheless, there has always been, and always will be "rationing" of medical ca’re. 6, 7 mechanic uses this term in the sense that care has never equalled demand, and notes that we are moving away from implicit, random rationing, dependent upon individual finance and local availability, towards explicit, systematic rationing by budgetary or policy decisions. The problem is the moral one of how to operate such a system within the ethical demands of medical practice, in which the 1. Cochrane AL. Effectiveness and efficiency. Random thoughts on the National Health Service. Nuffield Provincial Hospitals Trust: London, 1971. 2. Chronic renal failure: A priority in health? Office of Health Economics, 1978. 3. Office of Health Economics, 1980. 4. Report on the Work of the Prison Department. Home Office, 1979. 5. Brunner FP, Brynger H, Chantler C. Combined report on regular dialysis and transplantation in Europe IX, 1978. Proc Eur Dial Transpl Ass 1979; 17: 2-8. 6. Scarce resources in health care. Office of Health Economics, 1979. 7. Mechanic D. Future issues in health care. Social policy and the rationing of medical services. New York: Free Press, 1980.
thought of as the patients’ advocate, with a personal and commitment to them.8 Clearly, the medical profession and administrators cannot alone make decisions of this magnitude, but how the public should be involved is contentious. Starting with the broadest view, the size of any slice off the NHS cake depends most of all upon the size of the cake. Most of the public are unaware that we still spend less of our meagre national income upon health care than all other Western nations (5-5% of per-caput gross national product in 1979); and that this proportion has not increased in real terms since 1976.9 In addition, what we do spend is spent very efficiently compared with other EEC countries and the United States. By any criterion, the NHS is underfunded from the start, and this must influence local decisions as to what is possible. Also, the often-quoted failure of "modern" medical advances to make a major impact on overall mortality reflects only the change in our goals from seeking improvement in survival for the majority to a concern with quality of life and the survival for minority groups with relatively rare fatal disease. The only major impact on overall survival that is now possible would be to reduce the number of deaths from accident, suicide, and violence in the relatively young;9.1O we can no longer expect the great changes in mortality in those aged 15-45 brought about by public-health measures, antibiotics, and immunisation between 1900 and 1950. These belong to an era which is past, and it is naive to expect that we can ever add more than 5-10 years to present life expectancy." Any change other than a decrease in violent early death will in addition increase only survival in the 65-80 age group, from whom no direct economic return can be expected. A final point needs to be made. Golding and Tosey’s paper concerns the problem of a district health authority trying to cope with resource allocation when confronted by the demands of cardiac surgery and a renal unit. Surely here is not the forum where the costs of units dealing with patients from all over the region or even outside the region should be debated? For some reason-perhaps because they involve the transport and exchange of specimens, and not patients who require beds and food-regional and supraregional laboratory services have been planned and funded from the outset at regional or central DHSS levels; whereas clinical services serving a parallel function are funded, in general, at a local level. Despite their opinions to the contrary, at least a part of the dilemma faced by Golding and Tosey can be solved by a rational change in budgetary procedure. doctor is
contract
-
Renal
Unit,
Guy’s Hospital,
J. S. CAMERON
London SE1 9RT
IS BLOOD PRESSURE REALLY "WORSE" IN BLACK PEOPLE?
SiR,-Your editorial and Professor Sever and his colleagues’ on Black/White blood pressure (BP) differences (July 12) make fascinating reading. However, the central theory of
paper
the editorial that "far from being protected from hypertension the American Black seems more susceptible to the consequences" is doubtful, and the reference to "increased vascular complications" needs further qualification. Whilst the prevalence of hypertension by any criteria is higher in Americans of African descent, the level of pressure at which complications develop may be higher than in Whites. Langfordl has highlighted this finding from one of the very ...
8. Fried C.
Rights and health care-beyond equity and efficiency. N Engl J Med 1975; 293: 241-45. 9. Compendium of health statistics. Office of Health Economics, London, 1979. 10. Disorders which shorten life. A review of mortality trends for those between the ages of 15 and 44. Office of Health Economics, London, 1966. 11. Fries J. Aging, natural death and the compression of mortality. N Engl J Med 1980; 205: 130-35. 1. Langford HG. Hypertension in blacks. In: Onesti G, Buest AN, eds. Hypertension.
Philadelphia: F. A. Davis, 1978:
323-28.
THE COST OF HIGH-TECHNOLOGY MEDICINE SiR,-Dr Golding and Mr Tosey (July 26, p. 195) address an important question in their paper but do not discuss a number of equally important wider issues which might influence their conclusions. They also perpetuate the catchphrase of "new and expensive forms of high-technology medicine". All hospital medicine is high-cost; and salaries, not machines, account for three-quarters of the expense. Equally, "high-technology" medicine includes the development of vaccines and drugs which may bring about cheap treatment, or better still prevention. The difference between "modern high-technology" medicine and traditional hospital practice is that the former has usually been evaluated carefully, in terms of both fixed and variable costs on the one hand and survival and rehabilitation on the other. Older procedures have rarely, if ever, been subjected to similar cost-benefit analysis. Why should it be only new treatments which must be evaluated by controlled trials before they are introduced as Golding and Tosey suggest? Why not start by costing and evaluating the effect of any number of "established" treatments whose cost is high and whose value is, to say the least, in question?’ Each reader can, I am sure, supply his or her own list from their own field of practice without dif-
ficulty.
-
The myth that it is only technologically oriented medicine which is expensive dies hard. For example, the paper includes costings from the King’s group on dialysis and transplantation for end-stage renal failure, a condition fatal within days or weeks at most. (In passing, one notes that their costs of both home and centre dialysis are higher, and the costs of transplantation lower, than estimates arrived at by other authors.2 Also, the very small costs of transplantation after the first year are not brought out.) For comparison, the cost at 1980 prices of long-stay geriatric care is z7500 per year per patient, and care of long-stay mental handicap patients C6200 per year per patient. These costs are similar to keeping someone in prison (5900 per annum; or [,12 100 fbrahigh-securityprisoner[1979 prices]).4 All these figures are within the same range as keeping a patient in renal failure not only alive on dialysis but, in threequarters of all those treated, at work producing income.5 Transplantation is cheaper than any of the examples cited. The authors rightly point out that one cannot judge "benefit" in terms of economic return alone; if this were so then (for example) all hospice care should cease forthwith. Yet, when the grounds for curtailing life-saving treatment such as dialysis and transplantationare considered, these are precisely the grounds upon which (for example) the failure to treat patients over the age of 60 with renal failure is justified. The authors remark that it is "less acceptable" to restrict a proven technique such as dialysis and renal transplantation; this is untrue-it is unacceptable and has been found so in all other developed Western countries.5 Nevertheless, there has always been, and always will be "rationing" of medical ca’re. 6, 7 mechanic uses this term in the sense that care has never equalled demand, and notes that we are moving away from implicit, random rationing, dependent upon individual finance and local availability, towards explicit, systematic rationing by budgetary or policy decisions. The problem is the moral one of how to operate such a system within the ethical demands of medical practice, in which the 1. Cochrane AL. Effectiveness and efficiency. Random thoughts on the National Health Service. Nuffield Provincial Hospitals Trust: London, 1971. 2. Chronic renal failure: A priority in health? Office of Health Economics, 1978. 3. Office of Health Economics, 1980. 4. Report on the Work of the Prison Department. Home Office, 1979. 5. Brunner FP, Brynger H, Chantler C. Combined report on regular dialysis and transplantation in Europe IX, 1978. Proc Eur Dial Transpl Ass 1979; 17: 2-8. 6. Scarce resources in health care. Office of Health Economics, 1979. 7. Mechanic D. Future issues in health care. Social policy and the rationing of medical services. New York: Free Press, 1980.
thought of as the patients’ advocate, with a personal and commitment to them.8 Clearly, the medical profession and administrators cannot alone make decisions of this magnitude, but how the public should be involved is contentious. Starting with the broadest view, the size of any slice off the NHS cake depends most of all upon the size of the cake. Most of the public are unaware that we still spend less of our meagre national income upon health care than all other Western nations (5-5% of per-caput gross national product in 1979); and that this proportion has not increased in real terms since 1976.9 In addition, what we do spend is spent very efficiently compared with other EEC countries and the United States. By any criterion, the NHS is underfunded from the start, and this must influence local decisions as to what is possible. Also, the often-quoted failure of "modern" medical advances to make a major impact on overall mortality reflects only the change in our goals from seeking improvement in survival for the majority to a concern with quality of life and the survival for minority groups with relatively rare fatal disease. The only major impact on overall survival that is now possible would be to reduce the number of deaths from accident, suicide, and violence in the relatively young;9.1O we can no longer expect the great changes in mortality in those aged 15-45 brought about by public-health measures, antibiotics, and immunisation between 1900 and 1950. These belong to an era which is past, and it is naive to expect that we can ever add more than 5-10 years to present life expectancy." Any change other than a decrease in violent early death will in addition increase only survival in the 65-80 age group, from whom no direct economic return can be expected. A final point needs to be made. Golding and Tosey’s paper concerns the problem of a district health authority trying to cope with resource allocation when confronted by the demands of cardiac surgery and a renal unit. Surely here is not the forum where the costs of units dealing with patients from all over the region or even outside the region should be debated? For some reason-perhaps because they involve the transport and exchange of specimens, and not patients who require beds and food-regional and supraregional laboratory services have been planned and funded from the outset at regional or central DHSS levels; whereas clinical services serving a parallel function are funded, in general, at a local level. Despite their opinions to the contrary, at least a part of the dilemma faced by Golding and Tosey can be solved by a rational change in budgetary procedure. doctor is
contract
-
Renal
Unit,
Guy’s Hospital,
J. S. CAMERON
London SE1 9RT
IS BLOOD PRESSURE REALLY "WORSE" IN BLACK PEOPLE?
SiR,-Your editorial and Professor Sever and his colleagues’ on Black/White blood pressure (BP) differences (July 12) make fascinating reading. However, the central theory of
paper
the editorial that "far from being protected from hypertension the American Black seems more susceptible to the consequences" is doubtful, and the reference to "increased vascular complications" needs further qualification. Whilst the prevalence of hypertension by any criteria is higher in Americans of African descent, the level of pressure at which complications develop may be higher than in Whites. Langfordl has highlighted this finding from one of the very ...
8. Fried C.
Rights and health care-beyond equity and efficiency. N Engl J Med 1975; 293: 241-45. 9. Compendium of health statistics. Office of Health Economics, London, 1979. 10. Disorders which shorten life. A review of mortality trends for those between the ages of 15 and 44. Office of Health Economics, London, 1966. 11. Fries J. Aging, natural death and the compression of mortality. N Engl J Med 1980; 205: 130-35. 1. Langford HG. Hypertension in blacks. In: Onesti G, Buest AN, eds. Hypertension.
Philadelphia: F. A. Davis, 1978:
323-28.