Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
Undisguised Ageism
- Douglas G MacMahon, Susan Thomas, Policy Advisor on Chronic Disease and Disability, Royal College of Nursing, London. (23 July 2004)
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Rationing:the near future
- graeme m hill (27 July 2004)
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Response from CancerBACUP
- Joanne Rule (27 July 2004)
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NICE distorts investment priorities in cancer
- Graham Read (28 July 2004)
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Can NICE be turned into a NASTY?
- Sean P J Lynch, EX2 5AF (28 July 2004)
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Summary for busy clinicians
- Shaumik Adhya (29 July 2004)
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The trouble with being NICE is that you are often late
- Frank A Frizelle, Andrew Moot, Angus Watson (5 August 2004)
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Douglas G MacMahon, Consultant Physician Royal Cornwall Hospitals NHS Trust, Cornwall, England TR15 3ER, Susan Thomas, Policy Advisor on Chronic Disease and Disability, Royal College of Nursing, London.
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We find Maynard's attitude (1) quite as incredible as it is reprehensible, especially three years after the Govenment indicated that it was 'rooting out ageism' by the publication of the NSF for older people (2) - it has apparently failed - at least as far as the Health Economics Department of this Northern University is concerned and by the BMJ itself (3). The 'fair innings' approach is wrong on every count. It is as immoral to discriminate purely on chronological age as it is repugnant to victimise those born with genetic defects or on racial or religious grounds. It is also conterproductive to categorise a whole tranche of society as unworthy of treatment just on the single parameter of age. In this case it also happens to be a tranche that has already paid its dues for a 'cradle to grave' image of an NHS through taxation. We have seen enormous benefits to patients receiving appropriate care almost irrespective of age and both in the acute setting, in rehabilitation, and in chronic disease management. For this ageist point of view not only to be published in the BMJ but also supported by an editorial from the 'departing headmaster' should be a concern for all of us as we age, and for the probity of the publishers of the BMJ in particular. 1. Alan Maynard, Karen Bloor, Nick Freemantle. BMJ 2004;329:227-229 (24 July),Challenges for the National Institute for Clinical Excellence 2. Department of Health. 2001 National Service Framework for Older People, London, The Sationery Office 3. Smith R. BMJ 2004;329 (24 July)The triumph of NICE. Competing interests: DGM is geriatrician who is looking forward to a fairer society; past Chair, British Geriatrics Policy Committee. ST is Policy Adviser on Chronic Disease and Disability, Royal College of Nursing, London. |
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graeme m hill, pharmacist liverpool
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I disagree with the author on the mis-conception thst drug bills will for ever increase upwards. In the next few years ,on the primary care drug bill at least, pressure will subside. Please note thst many of the major drug developments of the 80's have now finished or about to finish their patent period ( the manipulations of the manufacturers not withstanding: Zispin Soltabs anybody?). If one is to assume that the history of Losec from a £28 patent to a £10 generic is typical then massive reductions will happen for statins, ssri, ACE 2 Inhibitors,etc etc. As many of the products have a proven efficacy record the pressure will lessen and a patient will clutch £20 of meds each month instead of £100 very very soon. Let NICE do its good work on the sole basis of evidence, let the market do the rest. Competing interests: own a pharmacy |
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Joanne Rule, Chief Executive CancerBACUP EC2 3JR
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Dear Sir, Professor Maynard and colleagues point out that treatments recommended by NICE can be expensive, but they are wrong to say that the “additional benefits of most treatments are small.” Some “may add only a few months to life”, but they may significantly improve symptoms from the disease at a time when quality of life is a crucial consideration. It should also be remembered that NICE approves drugs with other aims, such as those given following surgery to try to prevent cancer returning. Maynard and his colleagues say: “The NHS can’t afford NICE’s generosity.” They suggest giving NICE its own budget to fund the treatments it recommends, but surely this would lead to decisions based far more on cost than on clinical need? Furthermore, it would not solve the problem of postcode prescribing. NICE was set up to offer expert guidance on treatments that should be offered across the country, thereby ending the ‘postcode lottery’. CancerBACUP’s release of data on variations in prescribing patterns last October prompted a Department of Health investigation. The Department of Health’s subsequent report recognised this problem still exists but has failed to address the issue of who is responsible for the monitoring, implementation and enforcement of guidance issued by NICE. CancerBACUP has called for the new Healthcare Commission, set up to enforce national standards in healthcare, to fulfill this role. In addition, data on the tracking of the implementation of NICE guidance must be made publicly available to patients so they can assess how their local area is performing. Only then will the treatments all patients deserve be available to all patients – regardless of where they live. Joanne Rule Chief Executive CancerBACUP Competing interests: None declared |
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Graham Read, Consultant Clinical Oncologist Rosemere Cancer Centre, Royal Preston Hospital, Preston PR2 9HT
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Maynard et al. (BMJ 24 Jul 2004 p 227) are correct to draw attention to the problems caused by the selection of topics for NICE review. In Oncology the majority of reviews have been concerned with new cancer drugs. As purchasers are encouraged to regard these reviews as “must do’s” this effectively gives the funding of these drugs priority over other potential areas of investment. Many of these drugs are, in practice, only of short term benefit to the patient and often investment would be better placed in other areas such as diagnosis, surgery or radiotherapy. Competing interests: None declared |
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Sean P J Lynch, Honorary Senior Clinical Lecturer Mental Health Research Group, Peninsula Medical School, Wonford House Hospital, Dryden Road, Exeter,, EX2 5AF
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I think that the debate about the role and future of NICE is timely and it has been important to inject reality into the health rationing debate. The article leaves many more questions than answers, however, particularly on the feasibility and will to carry out many of the suggestions. Apart from the major ideological and ethical questions of whether we should ration at all - some questions that have struck me are when and how much we should ration and where public involvement in the debate about this process will come in. Surely this will need to be significantly expanded and made more transparent if NICE is to take on an explicit rationing role? Health funding is a dynamic and political process. Health budgets are always changing and they can change for many reasons, not all of which are directly economically driven. I think it is therefore somewhat naive to assume that there is already a consensus about rationing or even what our core health spend should be. Prioritsation is a difficult and political concept - who sets priorities for the greatest need and how will authorities stick to their decisions? Will unacceptable political choices result if driven by economic argument? What of the political influence of any "losers" in prioritisation? What is their mechanism of appeal or challenging the decision e.g. the increasing use of judicial review? As to the suggestions. I firstly have concerns about the comparability of treatments / technologies and health gains across many different specialties of medicine and health care. I therefore am highly sceptical that rationing or "re-prioritisation" could be easily achieved by a centralised NICE budget. It would be helpful if the authors could give clearer evidence-based indications of how this prioritisation could work, based on real-life examples of recent NICE decisions in different competing (for funds) areas of health care. Finally, I do agree that there is a useful debate to be had about stopping doing things that don't work too well or have not got a clear benefit, in order to fund other treatments or technologies. Competing interests: None declared |
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Shaumik Adhya, Cardiology Research Registrar University College London, WC1E 4JJ
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The National Institute for Clinical Excellence was sold to doctors and the public alike as a method of summarising the available information on the usefulness or otherwise of a variety of treatments. Whilst economic issues would be considered, and the cost-effectiveness of treatments calculated so that they might be compared, and ineffective tretments not recommended, NICE should be producing summaries that busy clinicians need to inform treatment, and not forcing rationing. I realise that in the real world, rationing is a necessary evil of funding health care; but it should be a role that the public and politicians should debate and assume. It should be for the payers to decide the level of service required - not the providers. Leave NICE to work out whether something's good for us. Finally, NICE should be berated for not containing a simple mission statement on their website, making it hard for the public and professionals alike to understand its purpose Competing interests: None declared |
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Frank A Frizelle, Professor of Colorectal Surgery Christchurch Hospital, New Zealand, Andrew Moot, Angus Watson
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The problem with being NICE is that you are often late. The gold standard in determining the effectiveness of a new intervention is the double blind randomised controlled trial (RCT). The results of multiple well-powered RCT’s lead to the highest levels of evidence. There are however frequently long delays in the reporting of trials and by the time the results are known the new technology is already in routine use . In areas were there is marginal benefit, the waiting may be advantageous. As put so clearly by Scott (1) when discussing the use of ultrasound to guide the insertion of CVP lines“ Do we need to mount more expensive trials … just to persuade a few Luddite losers to enter the 21st century?” Many new techniques will be adopted into clinical practise quickly if they are any good, long before NICE says yes to them. Surgeons, often , rely on level III or IV evidence when making decisions about emerging technologies. Data about cost-effectiveness in terms of QALYs is often not available. When it does become available it lags well behind data about efficacy. New technologies must therefore wait for this evidence to become available to obtain funding, Considerable delays are likely before patients within publicly funded health care systems (eg NHS) may benefit from them.. For example, it will be many years before the multicentre randomised controlled trials of sentinel node biopsy in early breast cancer tell us whether it is safe to omit axillary dissection ie when data on breast cancer specific survival and regional recurrence matures. For progress to continue clinicians need to have the resources to move forward together as specialist groups with lower levels of evidence that might otherwise be desirable until higher levels of evidence are produced including cost effectiveness data. It is important that “horizon groups“ develop for the rapid assessment and introduction of new techniques to improve patient care. We agree with Maynard A et al (1) that the primary role of agencies such as the National Institute of Clinical Excellence (NICE) should be to exclude established interventions or treatments that have been shown not to be cost effective, but not to prevent the introduction of promising new procedures or therapeutic agents. The RCT is only one way of assessing the suitability for introduction of new treatments. 1. Scott DHT. The king of the blind extends his frontiers. Br J Anaesth 2004; 93, 175-177 2. Maynard A, Bloor K, Freemantle N. Challenges for the National Institute for Clinical Excellence. BMJ. 2004 Jul 24;329(7459):227-9. Competing interests: None declared |
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