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Who decides what we can afford in healthcare technology?

rmhipmt26 March 2010

Both the major parties acknowledge the need to cut public spending after the election. Neither talks as if cuts are planned to NHS budgets. However, the NHS has always, in its 60 year history, enjoyed real-term increases in spending. A politician promising to protect NHS spending, is rather like someone promising not to halt a rising tide. If the next Chancellor manages to keep the NHS to zero growth, that will seem a huge success. Richard Smith, writing for the BMJ notes that NHS spending has tripled since 1979 and wonders what we have bought for the money: “In 1979 there were about 40 000 doctors and dentists in the whole NHS (it was one NHS in those days) but now there are 122 000 doctors (not dentists) in the English NHS alone. Nurses have increased less dramatically—from 300 000 in the whole NHS in 1979 to 400 000 in the English NHS now. In particular we have many more specialists. Cardiologists were exotic creatures when I was a junior doctor; now they’re a dime a dozen, all busy putting catheters in all day long.”
How did we decide that this level of spending is necessary? It can’t be that we “need” three to five times as many doctors as we did 40 years ago. The answer is that we don’t exactly “decide”. Tony Blair made a conscious decision to increase spending on the NHS, but he was probably responding to public perception of the quality of healthcare here compared to other wealthy European countries, following rather than shaping a public mood. Yet clearly the spending is driven by something, it is a function, somehow, of decisions that are taken by individuals responding to information picked up from contacts and colleagues.
I’ve been talking this week about the move from analogue to digital in breast cancer screening. This hasn’t happened in response to clinical need. Sure, the new machines have advantages over the old, but they don’t offer a step-change in performance. It seems rather that doctors are deciding to buy digital because they are conscious that manufacturers have stopped developing analogue. It doesn’t follow, though, that the process is straightforwardly determined by the manufacturers. The decision to switch to digital can’t have been an easy one for companies with a strong track record in analogue. My guess is that they were trying to provide what they expected customers to want and probably felt that the market was driving the shift. But the astonishing thing is that this cycle – customers making decisions based on what the market offers and the market offering what customers are expected to want – is taking place in a spiral of rapidly increasing costs. Digital mammography is roughly twice as expensive as analogue. Is someone somewhere making the judgement that that’s simply OK? Or maybe lots of people in different places are acting as though that is OK, because it’s hard to see how to act otherwise.