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EDITOR'S CHOICE: Tony Delamothe Why this unholy trinity? BMJ 2007; 335: 0 [Full text]

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The impacts of Bristol, Alder Hey and Shipman

Roger H Jones   (20 August 2007)

Sticking together - or sticking to standards?

Caroline Mawer, Douglas Russell   (21 August 2007)

The importance of being NICE

David Craig   (24 August 2007)

Trust in doctors

Jon Ford   (30 August 2007)

Effective new treatment for patients with advanced renal cell carcinoma

B W Hancock, P Nathan, A Ritchie, R Hawkins, J Wagstaff, J Anderson, N D James, P Patel, T Eisen, D Chao, M Gore   (11 September 2007)

The impacts of Bristol, Alder Hey and Shipman 20 August 2007
Roger H Jones, Wolfson Professor of General Practice King's College London, Department of General Practice, London, SE11 6SP Send response to journal: Re: The impacts of Bristol, Alder Hey and Shipman	Sir I am not alone in my surprise at seeing Tony Delamothe join Oliver Dearlove on the moral low ground to support his position on the public and professional impacts of Bristol, Alder Hey and Shipman (Editor's Choice, August 18th). I had thought that the days of unqualified confidence in medical self-regulation were long past. Above the shuffling of closing medical ranks I can hear the words of John Hampton's 1983 BMJ editorial on the end of clinical freedom...."at best a cloak for ignorance, at worst an excuse for quackery" .1 Dearlove demands evidence, as if an opiate. Lack of evidence of effect is not the same as evidence of lack of effect. He and Delamothe regard the DoH MORI polls as touchstones for public opinion, but a close reading of the questions asked in the 2001, 2003 and 2004 national surveys on GPs and specialists shows that the responses are likely to be driven largely by recent direct medical contact rather than by an appraisal of the health care system. Even then, 17% of patients questioned about cardiovascular care and 14% questioned about general practice and specialist cancer care had reservations or held negative opinions about the competence of doctors.2-4 However, the British Social Attitudes Surveys do indicate a decline in reported levels of public satisfaction with the NHS: for example the most recent results indicate a fall in ratings of satisfaction with general practice since the late 1990s, with over 16% of respondents expressing dissatisfaction, although comparable data on satisfaction with specialist care are not available.5 Following Alder Hey, Cancer UK reported a sharp fall in donations of tissue to the national tumour bank for children's cancer and 3000 families joined in a legal action against the NHS.Complaints received by the GMC had more than doubled by the turn of the century.6 Public concern about the behaviour of doctors and the regulation of medicine have been reflected in many publications,7-9 in the Reith Lectures10 and in a transformation of the ways that medical professionals and medical institutions may be held to account. To suggest that the political and professional responses to the 'unholy trinity' were a conspiracy between the government and the media is as bizarre as failing to recognise that the actions of individual doctors and hospitals were not isolated events but the 'alarm signs' of deeper problems. To caricature all this as an anti-medical machination of the Blair government seems to me the worst kind of medical spin References 1. Hampton JR. The end of clinical freedom. Br Med J (Clin Res Ed) 1983; 287; 1237-8 2. DOH (Department of Health) (2001b). National Surveys of NHS Patients: Coronary Heart Disease. London: DOH 3. DOH (Department of Health) (2003). National Surveys of NHS Patients: General Practice 2002. London: DOH 4. DOH (Department of Health) (2004). National Survey of NHS Patients: Cancer: Analysis of Themes. London: DOH 5. http://www.data-archive.ac.uk/findingData/bsaTitles.asp 6. Allsop J. Regaining trust in medicine. Current Sociology 2006; 54(4); 621-636 7. Irvine D. The Doctors’ Tale: Professionalism and Public Trust. 2003 Abingdon: Radcliffe Medical Press 8. Smith R. All changed, changed utterly. Brit Med J 1998; 316; 1917-8 9. Davies HTO, Shields AV. Public trust and accountability for clinical performance: lessons from the national press reportage of the Bristol hearing. Journal of Evaluation in Clinical Practice 1999; 5; 335-342 10. O’Neill O. A Question of Trust: The BBC Reith Lectures: 2002; Cambridge: Cambridge University Press Competing interests: None declared
Sticking together - or sticking to standards? 21 August 2007
Caroline Mawer, General Practitioner Tower Hamlets, London, Douglas Russell Send response to journal: Re: Sticking together - or sticking to standards?	Tony Delamothe talks about "tears of helpless laughter" when he considers the future of the medical profession - but we dont think the poor performance of large numbers of locum doctors is funny at all. Our evidence is observational and from just one general practice but unfortunately - and despite the undisputed examples of excellence out there(1) - we think it is widely generalisable. We have been using locum doctors as part of the salvage process for a high health need, inner city practice over the last six months. Many of these doctors miss potential 'red flags', have poor or very poor record keeping, poor prescribing, very poor referral practices and out-of-date management of long term conditions. Many of those from elsewhere in Europe dont know how the UK NHS works, or how to work in the NHS. Perhaps not surprisingly - since locums are generally unsupervised and unsupported - most dont seem to reflect systematically on their clinical practice. So far, in this one practice over the last few months, we have referred one doctor to NCAS (National Clinical Assessment Service) and another for formal investigation (potentially pending NCAS review). Dozens of others are being referred to their host PCTs. We realise that we are unusual in having an assertive quality process, routinely reviewing the day-to-day work of all our clinicians. We also realise that this level of review and referral takes up time and resources which we would, to be honest, rather spend on our patients. Maybe this is why no-one else has picked up these issues and these individuals. But this isnt really a good enough excuse. We think that there is widespread collusion between employers (often GPs, sometimes PCTs) who want holidays and other staff gaps filled; locum agencies who are apparently oblivious; and - perhaps most importantly - with other doctors who seem to be in denial about poor performance even when they actually notice it. If the profession continues to turn a blind eye, we cant be surprised if the government takes action. Roger Jones calls for professional unity. Surely this must mean sticking to our standards, rather than sticking together? (1) http://careerfocus.bmj.com/cgi/content/full/334/7608/242 (2) http://www.bmj.com/cgi/content/extract/335/7610/53?ck=nck Competing interests: None declared
The importance of being NICE 24 August 2007
David Craig, Senior Lecturer Queen's University of Belfast Send response to journal: Re: The importance of being NICE	Regarding the NICE decision on cholinesterase inhibitors for dementia, Tony Delmothe’s comments “bravo to NICE for sticking to its guns, and bravo to the High Court”, strike me as offensive and unnecessary. One assumes his own prescribing experience puts him in a strong position to express such one-sided opinions and he has personally found the cholinesterase inhibitors clinically ineffective. The worldwide expert view of these drugs is overwhelmingly positive but Delamothe, like others, appears to have been duped by the requirement by NICE to create arbitrary cost-driven cut-offs using modelling strategies which ride rough-shod over real-life benefit. There is some hope on the horizon however. The more publicity, good and bad, generated around NICE the more likely the NICE project will begin to eat itself. It is clear the Institute inadvertently acts as a giant pharmaceutical representative and approved drugs will necessarily acquire and benefit from the oxygen of publicity. The popular press will of course play their part, people will become patients, they will flock to their GP to see what they are missing, demand will rise and budgets will strain further. Where’s the health economic prudence in that? Competing interests: None declared
Trust in doctors 30 August 2007
Jon Ford, Head, Health Policy and Economic Research British Medical Association, Tavistock Square London WC1H 9JP Send response to journal: Re: Trust in doctors	The BMA does not take public trust in doctors for granted nor does it underestimate the potential for adverse public and/or patient reaction to events such as Bristol and Alder Hey. Accordingly, it has commissioned regular research via MORI on the issue and did so at intervals during the 1980s and 1990s and on an annual basis between 1999 and 2005. The findings support a conclusion of ongoing trust and belief in medical competence with little significant deviation even at times of highly adverse publicity. The public was asked whether it trusted a variety of professions and occupations to tell the truth and Figure 1 below shows the findings in respect of doctors over time. An additional question asked over the period 1999 to 2003 explicitly prompted respondents over negative publicity on doctors and asked whether in the light of this doctors did a good job or not. In 2000, specific reference was made to Bristol in the preamble and from 2001 onwards reference was also made explicitly to Alder Hey. Again the findings are set out in Figure 2 below. Neither set of findings appears to support the view that such events "shook the foundations of public trust and professional confidence." Furthermore, those respondents with experience of the NHS were more likely to state that they thought doctors did their job very well. Competing interests: The author is employed by the BMA
Effective new treatment for patients with advanced renal cell carcinoma 11 September 2007
B W Hancock, Professor YCR Academic Unit of Clinical Oncology, Weston Park Hospital, Sheffield S10 2SJ, P Nathan, A Ritchie, R Hawkins, J Wagstaff, J Anderson, N D James, P Patel, T Eisen, D Chao, M Gore Send response to journal: Re: Effective new treatment for patients with advanced renal cell carcinoma	The National Institute for Health and Clinical Excellence (NICE) may have many attributes (1), but speed of response is not one of them. Sunitinib and sorafenib, two novel multi-targeted kinase inhibitors, received a European licence for the treatment of advanced renal carcinoma after large randomised phase III studies (2, 3) demonstrated highly significant improvements in progression-free survival. In both these trials there were also trends towards improved overall survival, though these are going to be difficult to confirm statistically because of late cross-over of patients to the ‘experimental’ arms. In a disease that is refractory to most oncological treatments, these results were rightly perceived as a major advance and the drugs have been adopted as standard of care across most of Europe and North America. In the UK, NICE appraisal is not expected until the beginning of 2009. Primary Care Trusts, in the absence of a NICE outcome, are faced with the difficult task of making local health economic decisions, often without the benefit of expert oncological input. This inevitably leads to postcode prescribing. Some drug approval groups and commissioning bodies have approved use of these agents, but access has been denied to patients across many parts of the UK. Such inequalities are exactly what NICE was supposed to eradicate. If NICE is to do justice to the needs of UK patients with renal and other uncommon cancers, it must establish a mechanism that allows a truly rapid response when major therapeutic advances are made. A two-year interval between licensing and NICE appraisal for a disease in which median survival is less than a year is wholly inadequate. 1. Delamothe T. Editor’s choice: Why this unholy trinity? BMJ 2007;335(7615). 2. Motzer RJ, Hutson TE, Tomczak P, Michaelson MD, Buykowski RM, Rixe O, Oudard S, Negrier S, Szcylik C, Kim ST, Chen I, Bycott PW, Baum CM, Figlin RA. Sunitinib versus Interferon Alfa in Metastatic Renal-Cell Carcinoma. N Engl J Med 2007;356(2): 115-124. 3. Escudier B T, Eisen T, Stadler WM, Szcylik C, Oudard S, Siebels M, Negrier S, Chevreau C, Solska E, Desai AA, Rolland F, Demkow T, Hutson TE, Gore M, Freeman S, Schwartz B, Shan M, Sinatov R, Bukowski RM. Sorafenib in Advanced Clear-Cell Renal-Cell Carcinoma. N Engl J Med 2007;356(2):125- 134. Competing interests: Barry Hancock is on the advisory boards of Pfizer and Bayer and has given talks for these companies. He has received honoraria for this work. Robert Hawkins has received honoraria and or speaker fees from Bayer, Pfizer, Roche, and Chiron. Paul Nathan, Poulam Patel, and Nick James are on advisory boards and have given talks for Pfizer and Bayer for which they have received honoraria. They have also received sponsorship from these companies for educational meetings. John Wagstaff has acted as a paid advisor to Pfizer. Tim Eisen is on advisory boards for Pfizer, Bayer, and Wyeth and has given talks for these companies. He has received honoraria for this work. He has received research funding from Bayer and Pfizer. David Chao has been on advisory panels for Pfizer and Bayer and has given talks for these companies for which he has received honoraria. Martin Gore is on advisory boards for Pfizer and Bayer and has given talks for these companies. He has received honoraria for this work and also research funding. All other authors declare that they have no conflict of interest.