‘What can be more important than analysing who should get what treatments in the NHS?’

Dr Ed Wilson is a senior researcher in health economics at the Cambridge Clinical Trials Unit. He explains how his work helps decide which new treatments should be delivered in the NHS

Ed, tell us about your role
I’m split across two parts of the campus, half is at the Institute of Public Health at the Cambridge Centre for Health Services Research. That’s very primary care focused, looking at the economic factors of various policies. The rest of my time, I undertake economic evaluations alongside clinical trials, at the Cambridge Clinical Trials Unit.

How long have you worked here?
I have been here for two years. Before that I was a lecturer in health economics at the University of East Anglia (UEA) in Norwich. My first degree was in economics and finance, followed by a Masters in health economics, both at the University of York. Finally I completed my PhD in health economics at UEA, looking at the efficient design of clinical trials.

What do economic evaluations mean in research?
They take into account the value for money for a particular treatment. For example we could be looking at a new drug for a disease. In the clinical trial, the clinicians will be interested in knowing how well it works compared with either how patients are currently treated or against a dummy treatment known as a ‘placebo’. Alongside this, I will measure the cost of the new treatment compared with the current treatment or placebo.  This isn’t just the price the NHS has to pay to buy the drug, but the cost of all the associated care too, hospital stays, visits to the GP and other services such as rehabilitation and physiotherapy. I will compare the extra cost with the extra effectiveness of the new treatment to determine whether it is likely to represent good value for money for the NHS. 

This type of analysis is important as the NHS only has so much money to spend. If the NHS spends its money on one treatment for one group of patients it cannot spend that money on another. The analyses I do measures how much ‘health’ is generated by different treatments for every pound spent.  This ensures that the right decisions are made to allocate the NHS’s funds in a way that maximises the health of the population for the money available.

There are lots of stories recently in the press about NICE’s (National Institute for Health and Care Excellence) decisions to approve cancer drugs, do your reports have anything to do with NICE?
Some of them do, I work in a wide variety of disease areas. NICE looks at treatments that is likely to have a big impact on the NHS, such as the newer expensive cancer drugs. If NICE decides to look at a particular treatment, then my reports would be used along with other evidence to help decide whether it would be beneficial to implement it in the NHS. 

In the end it often comes down to whether the price the manufacturer wants to charge for their treatment is justified by the benefit it gives. A drug may be very expensive but if it is very good at either extending someone’s life or improving quality of life then that is reasonable. They then give the go-ahead whether the drug can be made available to NHS patients.  The difficulties come when the price is too high relative to the overall benefit.

Where do your reports go?
My reports follow a fairly standard academic approach where the results are published in ‘peer reviewed’ academic journals. This means that other economists and clinicians will review my work, check for errors and suggest changes. The journal editor then decides whether the work should be published. There will also be a full report submitted to the funder. Most of my work is funded by the NIHR, which is the part of the NHS that funds medical research. After this, depending on the results, and taking into account all relevant evidence, recommendations are made to either adopt the particular treatment routinely in the NHS, or to recommend rejection of the treatment and explore other ways to treat those patients.

Why did you want to get involved in health economics?
Both my parents were involved in health related areas, my father was a pharmacist and my mother a human biology teacher, so I’ve grown up around healthcare. I had a really inspirational economics teacher at sixth form and that got me interested in economics as a whole. I went onto study economics at university, then half way through my undergraduate course I came across health economics.

It seemed a good way to combine my interest in health and healthcare and having the tools of economics as a way to view the world and analyse decisions, and what can be more important than analysing the decisions over who gets what treatments?

Why were you interested in this area of research?
The analyses I do aim to understand and quantify the benefits and costs of different decisions on patients in the NHS. It’s a fascinating topic, to be part of the social sciences, the study of people and behaviour, of what people value and don’t value, and how to allocate the resources available to us and maximise the health of the population.

What does your role involve?
On a day-to-day basis from the outside it could look quite boring. Most of the time I’m at my computer or meeting with colleagues to check projects are on course, it depends on what’s happening and what stage different projects are at. Recently I’ve been spending a lot of time writing grant applications for new projects, editing reports and academic papers for others.  Soon I will be spending more time analysing data on my computer as the results of other studies become available. I travel to conferences to share my work, and learn about the results of other studies and of new techniques and methods. I also do a small amount of teaching and engagement with the public at various events.

Health economics is quite a new thing here at the campus, and I get a lot of clinicians contacting me to look at the economic issues around a particular intervention, which over the past two years means quite a lot of potential projects.  It could be a new treatment or drug, and the work starts by meeting with colleagues, planning the grant application describing the study we want to do, working out how much it will cost and submitting to a funder, which could be either the NIHR, Medical Research Council or a charity such as Cancer Research UK.

If we are successful then we obtain ethical approval, set up the study and collect the data. At this point, there is not much for me to do other than to make sure all the data I need is actually being collected as intended. Once the data is in then I carefully analyse it and write a report at the end. Hopefully we will find something new. It’s quite exciting at that stage when you have the data and it’s just been analysed and you’re the only person in the world that knows the results of the study. Then you have to write it up and tell people about it.

What kind of things are you for looking in the data?
I’m looking at cost-effectiveness. Say we were looking at a blood pressure pill, the clinician will want to measure the blood pressure reduction. As an economist I’m not just interested in the reduction in blood pressure, but the ‘so what’ - what is the benefit to the patient? In this case the benefit to the patient is a reduced risk of a heart attack, and so improving their quality and/or length of life if they take this pill. I will be interested how that pill will help on a longer term basis. I then also look at the resources used that may add extra cost to the health service and sometimes to the patient and their family or carers.

I will look if the potential patient may need any follow up treatments, such as additional check-ups with their consultant and GP or any other medication they may need to take. Finally, my analyses will weigh up the overall costs and compare these with the overall improvement in quality and length of life. This information is used by the NHS to determine whether the pill represents good value for money for taxpayers.

Why is your role in research so important?
It’s critically important to know not only the benefits of new and existing treatments, but also what they cost. When the budget of the NHS is fixed, a new cost incurred by one group of patients represents resources that must be taken away from another group of patients in order to provide the new treatment. My reports help quantify the costs and benefits to different groups of patients and so help inform whether a new treatment should be offered routinely. It’s ultimately up to the Secretary of State for health whether to introduce new treatments, but the reports I provide help with making that decision.

Why do you think research so important?
You will never know what works if you don’t actually look at it. If you don’t objectively and carefully design a fair experiment, you’ll never know whether the treatments available are the best ones.

After you’ve written and submitted your reports, how long does it take so patients can feel the benefits?
It all depends on the treatment we’re looking at. If we are looking at simple changes to care pathways that we think are much more efficient, and the results from the study were positive, we would be able to make the changes quite quickly so they wouldn’t take long to implement.

If you’re looking at a drug trial, it could take one-to-two years just to set it up. Firstly you have to persuade a funder that your idea is worth looking at, that you have the competence to carry it out and that you have fully thought it through. Then before you start you have to make sure everything is set up correctly to ensure patient safety, the research departments have to check it and then it has to be approved by an ethics committee to make sure there is minimal risk of patient harm. Then you have to look at how you capture the data. 

Depending on how big your trial is, it could take two years to recruit all your patients. You have to follow them up to see how the treatment worked which could be another two years or more. It has to be analysed and put in a report to the funder and peer-reviewed journals to show what you’ve found. You need to make sure the right action is taken on the results, which could mean presenting the results to relevant NHS staff and/or patients and communicating with the media.

For some studies it could be 10 or more years from initial ideas to information that changes clinical practice. However, these types of large scale studies with a very long follow-up period are how we found out how important it is for people with diabetes to keep tight control of their blood sugar levels, or that being very overweight carries risks of developing heart disease and diabetes.

How do volunteers help you with your research?
We almost always involve members of the public and patient representatives in the design of a study. It’s important they help you design the trial, so it’s designed in a way that works for the particpants. We always have lay representatives on the trial steering committees so they can give their input. Lay members play a vital role in making sure the clinicians are asking the right questions and also help us put documentation like leaflets in a plain English format that can be given to the participants of the study.

Why should people take part in research?
People should take part because you’re helping to improve knowledge. Taking part in research is trying to improve healthcare for future generations. We can treat more and more people and get better outcomes and learn about diseases. It’s something of a selfless act to take part in a research study.

Do all trials require you to test a new drug?
No, there are many different types of studies. Some are public health interventions such as healthy eating campaigns, or you may just need to listen to some dietary advice and use a pedometer to look at your physical activity. Other trials may need you to eat certain foods and have blood, urine or saliva samples taken, it depends entirely on what the study is looking at.

You’re never part of a drug trial unless you consent to do so and you can always withdraw any time without giving a reason, the ethics of research are always of paramount importance. Depending on the study, you may or may not receive a benefit from taking part yourself, it’s primarily a selfless act of doing something to benefit someone else in the future. 

The trials you’re involved with, is it only for people who have a chronic condition or can healthy volunteers take part?
I’m involved in all sorts of trials for different interventions. It can be from healthy volunteers, right to people who have advanced cancer, it’s a varied range of people who can be involved in research.

If people want to get involved in research, who should they contact?
There are patient and public involvement groups around such as INVOLVE, and they are a good place to start. There is information on the Cambridge University Hospital and the Cambridge BioResource websites, and you can always ask your clinician or GP for information about any studies they may be involved in.

What do you like to do in your spare time?
Outside of work, I enjoy singing, amateur dramatics and plays touch rugby in Norwich. I have been a singer since I was little, and was at one time the head chorister at St Peter’s Church Nottingham. I still occasionally sing with the choir of St Peter Mancroft, Norwich, although as a bass these days. 

I’m an enthusiastic member of the Norfolk and Norwich Operatic Society, having performed in many shows over the last 10 years. Since taking up this job in Cambridge I have less time to act, but still help out backstage in their productions. 

Finally, I’m also the treasurer of the Norwich Rebels Touch Rugby Club, a team which has grown from a few interested people kicking a ball about after work to an established community group benefiting from National Lottery grants, regularly attracting 30-40 men and women players each week, and hosting an annual tournament across Norfolk.

What would be your dream job?
I feel I have my dream job already, I love what I do and the opportunities Cambridge presents. Health economics isn’t well established here and there is a lot of interest in the discipline. Working at this well-known campus and being in Cambridge just adds the extra excitement to it.

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