Did you know that Offa’s Dyke is the “Line of Death”? In case you missed this bit of blatant party political rubbish from our Prime Minister, he said it in a speech in North Wales to local Conservative party members(1) recently. According to him, once you cross Offa’s Dyke (the ancient boundary between Wales and England for you foreigners) you go into a land where people are dying because of lack of good NHS care. The reason he wants to say that? Because health services in Wales are run by the party in opposition to him – the Labour Party, so he is saying that only the Conservatives can run a health service, as things are so much better in England. He goes on to say that waiting times for hip operations is much longer in Wales.

The impression you get from the London crowd, certainly in politics, is that nothing good comes out of Wales, ever. That is certainly the message I hear from friends in England, and in Scotland come to that. So let’s go into what David Cameron said a bit further. On the Offa’s Dyke story, was he talking about life expectancy? No, because Wales despite being poorer, life expectancy is hardly less than England, and has been catching up in the last four years. No, he was actually talking about end-of-life medicines. These are the new cancer drugs on which many Pharma companies are expending a lot of their energies. Remember Herceptin for breast cancer? This was one of the first big issues to hit the headlines, as patients (worked up through the media mainly by the drug manufacturer) clamoured for this very expensive treatment and objected to the time it was taking to become available. In the end the drug company and the media won and it was fast tracked, at enormous expense, but the ultimate result was that it really didn’t live up to expectations and helped very few people(2).
The new cancer drugs that are coming on stream now are mostly ones which provide only a very limited extension of life. And because there are far fewer people who need this sort of treatment than people who need treatment for blood pressure for instance, they have to be priced very highly. So how much would you pay in a free market, say, for 4 months extra, not high quality life? Already you will have many symptoms from your disease, you may be weak and in pain, and the new life prolonging treatment may actually make you feel worse. On the other hand, life is irreplaceable and the thought of death, final death, inconceivable. Saving lives is very emotive. There are patients’ pressure groups, often funded by the drug companies, and such hard choices make for very good newspaper copy. So, would £10,000 pounds for 3 months be about right? If you, the patient, had the money yourself, and had no-one you wanted to leave it to – why not? For the guardian of the public purse, NICE, the usual cost limit is £30,000 per quality year. But for these really difficult end of life cases, public pressure (from the patients and doctors’ lobbies via the media) has resulted in an increase to £40,000 per year, despite the lack of quality of life. But in a cash strapped health service, the payers, CCG’s in England, can’t actually afford this.

So, for political reasons, England has found the money from elsewhere and has established the Cancer Drugs Fund, which can pay this excessive amount for selected patients to access the them. Wales hasn’t played this game. NICE says it isn’t cost effective, and Wales certainly doesn’t have the money. People in Wales are poorer on average, and there are many other more pressing needs, so there is no such cop out available here. This is what David Cameron is referring to. It is a cheap, inaccurate and unfair political point, and actually hasn’t helped his Conservative candidates in Wales at all. It just put peoples’ backs up.

For every patients who wants to hang on to life as long as possible, at whatever level of suffering, there are also many who don’t ask for these drugs, and accept that their time has come. A close friend of mine, dying of oesophageal cancer, told me that she had refused offers of further therapy, after surgery, radiotherapy and chemotherapy had failed. She chose the time of her dying, with dignity and acceptance of death, and died peacefully after relatively little suffering, with her family around her.

Doctors don’t usually choose these end-of-life treatments for themselves. A recent study from California (3) showed that “Most physicians (88.3%) would choose a do-not-resuscitate or “no code” status for themselves when they are terminally ill, yet they tend to pursue aggressive, life-prolonging treatment for patients facing the same prognosis.” It goes on “A big disparity exists between what Americans say they want at the end of life and the care they actually receive. More than 80 percent of patients say that they wish to avoid hospitalizations and high-intensity care at the end of life, but their wishes are often overridden.”

It is no different in the UK. So why should this happen?
The author says the problem is that doctors are trained to be active and do things. “We don’t train doctors to talk or reward them for talking. We train them to do and reward them for doing. The system needs to be changed.”
I quite agree. The trouble is that it is politics that gets in the way. One story in the media and patients get really angry that they are not getting their “fair share”.

David Cameron also talked about waiting lists for hip surgery, which are longer in Wales than in England. In my view waiting lists are not too long – many doctors think they are too short. People are now having hip and knee surgery when they have only minimal symptoms. All such operations have a risk attached, a surgical risk, and an anaesthetic risk, and the prostheses only last 10 years or so. Each successive “revision”, where a new prosthesis is put in, will cause new problems. I remember a lady, very wealthy, who started having hip operations in her early 60’s (privately, as she would have had wait years on the NHS) but by her early 80’s was in a wheelchair because of complications after the fourth “revision”. I think she would have done better if she had waited longer before having the first operations. I certainly don’t want to get back to the times in the early noughties when you could wait 4 years, but a wait of 6 months is not unreasonable.

Public expectations are very high; we are not supposed to die, we aren’t supposed to have any disability, or it is the fault of the health service. And that is why politicians score these cheap points.

In fact, the same day that the Prime Minister made these comments, a report came out from the Nuffield foundation comparing the four health systems(4), in Wales, Scotland, Northern Ireland and England. It wasn’t reported at all in the press, but it said in effect that the gap between the NHS in England and the rest of the UK has narrowed in recent years, so that now no country is consistently ahead of the others, despite all the hype about how England has improved with increased competition and privatisation. More recently a survey(5) has been published showing that people in Wales are in fact very satisfied with their health service – more satisfied than people in England. All countries are having problems in funding health services in times of austerity, and all have their scandals. Everyone has to make sure that every penny is spent according to the evidence of what works and does not work, and our politicians should be taking this on board, rather than scoring cheap points at each other.

1. http://www.telegraph.co.uk/health/nhs/10760842/Offas-Dyke-is-line-between-life-and-death-says-David-Cameron.html
2. Two breast cancer drugs not cost effective, says final NICE guidance. NICE, 2012. http://www.nice.org.uk/newsroom/pressreleases/TwoBreastCancerDrugsNotCostEffective.jsp
3.htmlhttp://www.sciencecodex.com/most_physicians_would_forgo_aggressive_treatment_for_themselves_at_the_end_of_life-134539
4. http://www.nuffieldtrust.org.uk/our-work/projects/funding-and-performance-health-care-systems-four-countries-uk
5. http://www.bbc.co.uk/news/uk-wales-27616963