Deciding how to treat any patient is a complex challenge.
Need must be balanced with available resources. This becomes acute in relation to life-threatening conditions such as heart disease. As The Herald revealed this week, heart patients in Scotland are being denied treatments which are now standard in the rest of the UK and Europe. Ticagrelor, a blood-thinning drug, is expensive compared with current treatments but was approved for use by the Scottish Medicines Consortium (SMC) 18 months ago because it significantly increases the chances of survival. However, it is still not in general use because there has been no national agreement on which patients should receive it.
This delay and the unavailability of a less invasive valve operation as an alternative to open-heart surgery in Scotland was bitterly criticised by Professor Keith Oldroyd, director of research and development at the flagship Golden Jubilee National Hospital in Clydebank, in an interview with our health correspondent. He warned that Scotland lagged years behind the rest of the UK and Europe. The time limit for emergency insertion of a stent in a blocked artery, for example, is 120 minutes after a heart attack in Europe but still only 90 minutes in most of Scotland.
The discrepancies deserve closer scrutiny. The chair of the Scottish Government's national advisory committee on heart disease, Dr Barry Vallance, tells The Herald today, that the delay in introducing ticagrelor is not due to cost restraints but to three separate views among regional groups of cardiologists about which patients should receive it. It is important that consensus is reached for two reasons. First, the criteria must achieve the best outcome for patients. Secondly, they should also apply uniformly across the country to avoid the development of a postcode lottery.
As the frontiers of medicine are being pushed back at an extraordinary rate, it is important that new techniques and treatments are properly evaluated. Not all will benefit every potential patient. Dr Vallance argues that Scotland's caution in introducing new procedures is the right approach. In particular, he warns that TAVI (transcatheter aortic valve implantation), the technique for high-risk patients as an alternative to open-heart surgery, which is not available in Scotland, is not a wonder cure.
Nevertheless it is unacceptable that a treatment that significantly increases the chance of survival is standard in England but not available, or requires special pleading, in Scotland. When new drugs are approved for use in the NHS in England and Wales, health trusts are required to introduce them within three months. However they then bill primary care trusts for the cost. In Scotland, funding is via health boards responsible for financing the full range of services. This requires increased costs in one area to be balanced by cuts elsewhere. It is right that the most expensive new treatments are implemented with caution. Cost-benefit decisions are undeniably difficult but, once a new medicine has been approved, a timeframe for its introduction should be considered in the move to consistency.
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