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LETTERS: Timothy S Maughan and Joanne Rule Ethics of PCT decision making on funding cancer treatments BMJ 2008; 337: a1243 [Full text]

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The primacy of the individual patient

David M Bowker   (20 August 2008)

The primacy of the individual patient 20 August 2008
David M Bowker, Retired Consultant Psychiatrist Cheshire SK7 2LL Send response to journal: Re: The primacy of the individual patient	Doctors who have been cajoled into believing that they can balance in some way the immediate needs of the patients in front of them and some notion of "optimal care to all patients.........in an economically limited system" have taken an insoluble route which no new national guidance will alleviate. Traditionally doctors have been concerned with the individual patient and there is a strong argument that they, with the patient, are the best qualified and most prudent of potential managers to decide on appropriate treatment however expensive. The high costs associated with some treatments make an organisation such as NICE a reasonable proposition as long as the remit of that organisation is simply to decide on effectiveness in the sense that this can be spelled out in terms of potential prognosis. QUALYS are of no interest to practicing clinicians, or the individual patient, and should be of no interest to NICE - they simply muddy the waters of otherwise sensible judgements of value which could be made, and exist simply to amuse academic health economists generalising about issues of health and treatment and to justify central interference in clinical issues . It is no endorsement to say that other countries are looking with interest at NICE - what politician could resist it. My understanding is that NICE does not have a central pot of money which it can in some way rationally and equitably distribute amongst all patients for all treatments (surely an impossible goal for any bureaucracy) , rather it saves a notional amount of money by not approving treatments but there is no guarantee that any money not spent will avoid waste in ludicrously ambitious and wasteful IT schemes or decorating offices. Sadly some would say that doctors have lost the high ground in any debate about the primacy of the patient by being quite crudely bribed - those extra sessions to reduce waiting lists - and blackmailed - funds will be withdrawn from units if central targets are not met, but this could be regained to some degree if once the issue of effectiveness is decided, decisions on treatment are left with doctors, not PCTs or NICE.. It would cost less, as well. Competing interests: None declared