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Health and Sport Committee 15 March 2016

15 Mar 2016 · S4 · Health and Sport Committee

Item of business

Chief Medical Officer’s Annual Report 2014-15

Dr Calderwood Watch on SPTV

I am pleased that you brought that up, because I had considered including a chapter on value-based medicine. However, coming back to Mr Chisholm’s point about controversy, I decided that it was a little bit too controversial for my first annual report. Perhaps I will include it next year. I entirely agree with you. We have the quality-adjusted life years measure, and we apply it rigorously to drugs, because they have a cost; someone has to pay for them. An example that Dr Milne will be familiar with relates to someone with head and neck cancer, who will have a five-hour operation and a further five-hour operation several days later and will then spend a prolonged period of time in intensive care. We do not evaluate the cost of that treatment or have a conversation about whether, on cost or on some other basis, it should be carried out. We do not come out at the end with a price tag. I have deliberately chosen that example, because it actually has a significant price tag, and it often has a poor outcome; in other words, a low amount of additional quality of life is gained from it. It is almost inequitable to have the same conversations about drugs, just because they have a price ticket on them, and not have such conversations about other areas of practice. It almost disadvantages the people who need the drugs. As you might know, before starting this job, I worked part time for a couple of years for Bruce Keogh in NHS England. Under the English commissioning system, the cost is carefully looked at. For example, a receiving trust will have a menu; if someone comes in for that head and neck procedure, the trust will predict, as far as it can, the length of stay in the intensive care unit. That comes with a price on it, and the referring trust will have to talk about that cost and where it will find the money to meet it. In England, my mindset was that that was the way that the system worked, and I think that many more doctors in England are aware of that than doctors in Scotland, simply because we do not have to be aware of it. Sitting behind us is Christine Gregson, a junior doctor in Lothian who is also acting as clinical leadership fellow in my office for a year. She must take some credit for the report—she was my editor-in-chief—and I have asked her to look at this subject to see whether there is any appetite for looking at the value, down to cost, of some of those other procedures. I will also be speaking to some of the chief executives in NHS Scotland, as they, too, might be interested. However, what we do with that information concerns me, because this is not about rationing. It is not about saying, “Your procedure’s too expensive” or “You aren’t someone we think that the money should be spent on.” Maybe that is the danger zone that I did not want to stray into in my annual report. However, we could turn it the other way, because what I saw in England was that it drove quality of care. A trust would not be paid unless it provided a multidisciplinary team, specialist nursing and so on. Of course, it was all decided by GPs; the trusts that gave very good care got more business, and the ones where the GPs did not think that the care was as full, as specialist or as good were not sent any patients. You could turn it into a positive discussion, but it would be difficult to do.

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Health and Sport Committee 15 March 2016

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