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Thanks Adam, and to all of you for comments. Alan is currently heading for a Spanish beach with many grandchildren, but I don't suppose that will stop him from joining in when he reaches a wi-fi zone. In the meantime, I think our concern was that life 'saving' drugs (more realistically those that might extend the life of someone with a terminal illness for a few months) are increasingly being treated differently from those that contribute to quality of life. This seems a return to the pre-Alan Williams days of measuring the success of interventions purely by whether or not they extend life, regardless of quality. QALYs, however clumsy they might be, attempt to combine length and quality of life using a common metric, but this is undermined by setting different thresholds when we feel like it. And Jennie, I don't think the benefits of your mother's ballroom dancing and french lessons are 'immeasurable' necessarily - sounds to me as if they would contribute at least to the mobility and depression domains of EQ-5D - although I think your chances of NHS funding could be slight. My view, for what it's worth, is that at the end of life, people value most care that provides pain and other symptom relief, and maintains dignity. There could be a need to look at how we measure these if we don't think that standard measures of quality of life are enough. But we need to stay robust in assessing the value of overpriced drugs of marginal effectiveness. Enjoy your weekends. Karen On May 29 2009, Adam Oliver wrote: >Dear David, Jennie et al. > >These interventions may be all well and good, but I think Alan and >Karen's article was principally motivated by the case of very expensive >drugs being funded when they offer very small benefit (if you're lucky) >- Alan: correct me if I'm wrong. This is got relatively little to do >with age, I think. You might get colon cancer when you're, 30, 40, 50, >120... > >If you go the pure economic evaluation health maximization route, there >is no way you ought to fund these drugs at current prices, either from a >public payer, or from a private payer (funding such drugs in a private >market increases premiums, decreases coverage etc). I do think there is >more to the pure health maximization route in these cases, something to >do with offering dignity when one reaches the end of life, maybe >something to do with the end of life signifying the quality of a whole >life (I think Aristotle said something along those lines). I haven't >worked it out yet, and maybe never will, but there clearly seems to be >something of profound import that people attach to the end of life. > >However, some of these drugs are ridiculous, aren't they? Pharma execs >are buying their second homes in the Napa Valley and god knows where >else and even now are receiving ludicrous bonuses, and the industry as a >whole is constantly pleading poverty. In short, the industry is charging >far too high a price for these products, and we shouldn't lose sight of >that. Their avarice is harmful to society (i.e. to all of us), and thus >there does need to be a focus on whether what we get for these products >is worth what we pay for them. > >Very best, >Adam > >-----Original Message----- >From: Anglo-American Health Policy Network [mailto:[log in to unmask]] >On Behalf Of David McDaid >Sent: 29 May 2009 23:00 >To: [log in to unmask] >Subject: Re: NICE WOBBLES > >Yes just to follow up on Jennie's comment - NICE has been looking at the >evidence on interventions to promote mental and physical wellbeing in >older people. > >There are some well designed studies indicating not only benefits from >the exercise per se; but also older people (as anyone else) also benefit >from social participation that comes de facto alongside these exercise >activities. Exercise is just one a range of interventions that can help >reduce the risk of serious falls and potential risk of fracture which >can be so debilitating to individuls in both mind and body - and indeed >costly. This is to say nothing of the role that exercise and other >groups activities can have in helping to reduce the risk of serious >depression and suicide in older people. > >Again there is a growing evidence base that a range of modest community >based activities can both help with quality of life and as also as it >happens be cost effective. It would be good if health care systems were >to more systematically consider how best to support some of the >community based interventions even when they fall beyond the boundaries >of the conventional health care system. > > >Best wishes > >David > >-----Original Message----- >From: Anglo-American Health Policy Network [mailto:[log in to unmask]] >On Behalf Of Popay, Jennie >Sent: 29 May 2009 22:33 >To: [log in to unmask] >Subject: Re: NICE WOBBLES > >If I could intervene here - hints of ageism here. My 87 year old >working class mother with advanced heart failure goes to ballroom >dancing classes every Friday evening. She doesn't do a great deal of >vigorous activity (!) but that and her weekly French classes >contributing immeasurably (well at least from the perspective of the >non-economists) to her continued high spirits and her ability to remain >active and cared for at home despite considerable ill health - >presumably worth a bob or two to the NHS and/or social care budgets. >Jennie Popay > >-----Original Message----- >From: Anglo-American Health Policy Network [mailto:[log in to unmask]] >On Behalf Of Adam Oliver >Sent: 29 May 2009 15:50 >To: [log in to unmask] >Subject: Re: NICE WOBBLES > >Well, ballroom dancing is increasingly popular. > >-----Original Message----- >From: Anglo-American Health Policy Network [mailto:[log in to unmask]] >On Behalf Of Roebuck, Chris >Sent: 29 May 2009 15:37 >To: [log in to unmask] >Subject: Re: NICE WOBBLES > >E.g., Hip Replacement for 90 year olds. >This is the one I've heard brought up at several conferences. > > >-------------------------------------------------- >M. Christopher Roebuck >Director, Health Economics > >CVS Caremark | Strategic Research >11311 McCormick Road, Suite 230 >Hunt Valley, Maryland 21031 >Phone: 410.785.2136 >Fax: 410.785.8140 >[log in to unmask] >-------------------------------------------------- >CONFIDENTIALITY NOTICE: This communication and any attachments may >contain confidential and/or privileged information for the use of the >designated recipients named above. If you are not the intended >recipient, you are hereby notified that you have received this >communication in error and that any review, disclosure, dissemination, >distribution or copying of it or its contents is prohibited. If you >have received this communication in error, please notify the sender >immediately by telephone and destroy all copies of this communication >and any attachments. > > >-----Original Message----- >From: Anglo-American Health Policy Network [mailto:[log in to unmask]] >On Behalf Of Gemmill, Marin >Sent: Friday, May 29, 2009 9:24 AM >To: [log in to unmask] >Subject: Re: NICE WOBBLES > >Alan, > >Thanks for forwarding the article - one of your paragraphs brought up a >key point that I'm interesting in hearing other views on. That is, >should we prioritize products that extend the life of or the quality of >life of those with terminal illnesses? And I would go further in asking >how much should third parties be willing to pay for end-of-life care? I >think this debate has major implications not only for the UK but also >for the US where we essentially prioritize end-of-life care for the >insured over covering our 46 million (or so) uninsured. > >Marin > > >Marin Gemmill-Toyama, PhD >Senior Research Analyst, Strategic Research CVS Caremark > >Phone: 410-785-3346 >Fax: 410-785-8140 >[log in to unmask] > >-----Original Message----- >From: Anglo-American Health Policy Network [mailto:[log in to unmask]] >On Behalf Of Maynard, A. >Sent: Friday, May 29, 2009 4:02 AM >To: [log in to unmask] >Subject: NICE WOBBLES > >This piece by Maynard and Bloor will appear in the July JRSM. >I hope it is of interest >Best wishes >Alan > >-------- Original Message -------- >Subject: Proof of article jrsm-10.1258/jrsm.2009.09k031 for >Journal of >the Royal Society of Medicine[Spam score: 8%][Scanned] >Date: Fri, 22 May 2009 16:51:51 +0100 >From: <[log in to unmask]> >Reply-To: <[log in to unmask]> >To: <[log in to unmask]> >CC: <[log in to unmask]> > > > >Dear Author, > >Please find below a link to your paper for Journal of the Royal Society >of Medicine in Portable Document Format (PDF). > >PDF files can be opened using Acrobat Reader, which can be downloaded >free of charge. If you do not already have Acrobat Reader, simply visit >http://www.adobe.com/products/acrobat/readstep.html > >Instructions about return of proofs and a Copyright Transfer Agreement >(if applicable) are included in the file, please read these carefully. > >This Proof is sent to you on behalf of Royal Society of Medicine Press >Limited. > >If you are unable to download the pdf proof email: >[log in to unmask] > >For any other queries about the proofs email: [log in to unmask] > > >PDF Proof >http://www.henryling.co.uk/net/rsm/downloads.aspx?id=fpjrsmm320riitpbepg >a55wftlgxjw515109k031 > >Please access the attached hyperlink for an important electronic >communications disclaimer: >http://www.lse.ac.uk/collections/secretariat/legal/disclaimer.htm > >Please access the attached hyperlink for an important electronic >communications disclaimer: >http://www.lse.ac.uk/collections/secretariat/legal/disclaimer.htm > > Please access the attached hyperlink for an important electronic > communications disclaimer: > http://www.lse.ac.uk/collections/secretariat/legal/disclaimer.htm