One key aspect of working in a resource poor environment is that I am constantly having to make decisions about how to allocate the scarce supplies that are available. I have been thinking recently about how the people from the National Institute for Clinical Excellence (NICE) must feel, when they make decisions on which treatment will and more importantly, will not be available on the NHS.
I saw a patient this week, a 42-year-old woman who has 5 children aged between 7 and 17. The family live in a small community and work hard, long hours as rural farmers. Their income is a bit more than the minimum wage for two adults, around £200 per month for the family. Following a consultation with a GP in the city, the extended family followed the GP’s advice and paid for a consultation with a specialist in the city of Cochabamba, 4-hour bus ride away. His time and investigations cost around £75 and he confirmed a diagnosis of uterine cancer. A course of chemotherapy and radiotherapy will cost 10 times the initial costs and carry no guarantee of a cure. When they heard that I was having a clinic in their village, they asked for my help. £750 is more than double my monthly budget for medical supplies (a budget provided by kind donations from family and friends and for which I am eternally grateful). If I was to help this one patient, I would deprive scores, if not hundreds of other patients of treatment for their infections, pain and other (albeit non-life threatening) problems.
I am a junior doctor with coming up to three years experience. If you had told me 12 months ago that I would be making decisions about budgets and treatment availability, I would have thought you were mad. This patient’s case was extreme and I went back to a deal that I had made with myself at the start of this project – that I couldn’t possibly help everyone. However, on a weekly basis I have to decide whether I can cover the costs of other tests and investigations. Blood tests are fairly cheap, X-rays a bit more expensive, ultra sound scans hit my monthly budget hard and an endoscopy (if I could get the patient to the city of La Paz) would take over half a month’s money.
So, I find myself relying much more heavily on my clinical skills to make a diagnosis, without the tests and investigations that would be automatic in the UK. It is far from ideal and I wish that I could have access to every possible treatment option. The fact is, I don’t and the experience will make me think long and hard before criticising anyone from NICE again, when they declare a treatment unavailable for NHS use due to budget restrictions.