Equity in the new NHS

BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7321.1127 (Published 10 November 2001) Cite this as: BMJ 2001;323:1127

Small groups should not undertake responsibilities on their own

  1. Daphne Austin, consultant in public health (Daphne.Austin{at}wha.worcester-ha.wmids.nhs.uk)
  1. Worcestershire Health Authority, Worcester WR4 9RW
  2. King's College London, Lewisham Hospital, London SE13 6LH

    EDITOR—Doyle's refreshing article describes the daily realities of priority setting faced by commissioning bodies.1 The article also provides a welcome counterbalance to the unrealistic hype over the National Institute for Clinical Excellence (NICE) being hailed as rational decision making in the NHS and the answer to postcode prescribing.

    Commissioners are given the task of making difficult funding decisions in a politically and socially ambigious milieu. In undertaking this task I give caution over the practice of agreeing exceptions on compassionate grounds. I support Doyle's suggestion that this is often a means to bypass the evidence. It is often seen as a useful tool to avoid getting caught over the “never say never” directive. This is because agreeing some exceptions shows that the organisation does not “fetter its discretion” (the term for this type of transgression by public bodies).

    There is much to recommend expressing compassion in the NHS—we all expect it—and I do not undervalue the collective benefit gained from the belief that this expectation will be met. But what does “accepting on compassionate grounds” mean in the context of resource allocation? We have grappled with this locally and have come to the conclusion that all too often it means agreeing funding for those who shout loudest.

    Furthermore, you can also find yourself in darker waters. Exceptional reasons presented to us often include keeping a person in employment, being a mother, being comparatively young, etc. A decision made on the basis of an exception may therefore come down to defining the worth of an individual to society or applying an arbitrary hierarchy of tragic circumstance. These are not the kind of decisions I am comfortable making, for all sorts of reasons, not the least of which is some notion of equality. I also find it uncomfortable to dress value judgments up as pseudoclinical decisions to make a decision more palatable. I have seen this happen at all levels of the NHS over the years. I recommend avoiding doing both of these things.

    Both as citizen and public health professional I am willing to participate in priority setting processes and see it as a responsibility. But the current situation of having small groups of people bear much of the burden of value based decisions is a reflection that society continues to bury its head in the sand, thereby abdicating from a key responsibility. While this is understandable, I fear that commissioners are all too quickly and conveniently cast in the role of scapegoat as a result.


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    Evidence cannot help in all situations

    1. A J D Macdonald, professor of old age psychiatry (alastair.macdonald{at}kcl.ac.uk)
    1. Worcestershire Health Authority, Worcester WR4 9RW
    2. King's College London, Lewisham Hospital, London SE13 6LH

      EDITOR—I was one of the prescribers of donepezil for a patient in Merton, Sutton, and Wandsworth while that health authority maintained its refusal to fund its NHS prescription. Doyle gives a glimpse into the authority's reasoning and approach.1 She gives the impression of a rational, evidence based purchasing organisation surprised, and aggrieved, at the apparent triumph of public emotion over reason.

      The idea—supported by Austin in her electronic response (www.bmj.com/cgi/eletters/323/7306/222#EL4; letter above) —that something called “compassionate” use of the drug might be viewed as a way around the evidence is astonishing. All good medical practice is founded on compassion, an emotional response to distress in patients or carers. The decision to prescribe is based on this emotion, but using evidence as a tool—in this case to help us decide on the ratio of benefit to risk of not treating versus treating. It seemed obvious from the evidence that the average “modest” benefit of donepezil was likely to be a net result in a mixture of good and poor responders, and no one knew (or yet knows) who was who.

      Given the evidence, prescribing is the evidence based practice we are all urged to follow. Doyle's, and now Austin's, error seems to be that they confuse evidence based practice with the oxymoronic evidence based purchasing. What evidence, however clear, cannot do is to tell you whether to fund an expensive drug with a modest impact on a widespread, devastating, and previously pharmacologically untreatable disorder, or ask Philip Morris to help reduce the chances of anyone living long enough to develop it. Only emotion can help us there.


      • Eli Lilly has funded refreshments at countless training events for senior house officers, several lectures for general practitioners, and a few receptions at international conferences in which AJDM has participated. They have also contributed or met his travel expenses and accommodation costs for two conferences in Europe. AJDM does not smoke.


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