BMA Annual representative meeting, Manchester, 27 - 30 June: NICE undermines doctors' clinical freedom, say BMA representatives
BMJ 2005; 331 doi: https://doi.org/10.1136/bmj.331.7507.12-e (Published 30 June 2005) Cite this as: BMJ 2005;331:12All rapid responses
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Dr Arnold's attack on NICE - the National Institute for Health and
Clinical Excellence (BMJ 2005;331:12) - at the BMA's ARM is rather wide of
the mark.
First, NICE has not "banned" the use of atypical antipsychotics in
elderly for reasons of cost ineffectiveness or any other grounds. It has
endorsed the use of these drugs in schizophrenia (1) but hasn't produced
guidance for their use in other situations. Dr Arnold is probably
referring to advice from the chairman of the Committee on Safety of
Medicines (2) who, in March 2004, warned of the increased risk of stroke
when atypical antipsychotics are used in elderly patients with dementia.
Professor Gordon Duff's advice was based on safety and nothing to do with
cost.
Secondly, QALYs are not "inherently ageist". There have been a
number of occasions, such as the use of biphosphonates in the secondary
prevention of osteoporosis (3), where NICE has shown increasing cost
effectiveness with age.
Finally, as a practising clinician, I am as aware as anyone that
NICE's clinical guidelines cannot (and should not) be applied
indesriminately to all patients with a particular condition. And this is
made abundantly clear in all our guidance documents.
Yours sincerely
Michael D Rawlins
1) National Institute for Clinical Excellence. Guidance on the use
of newer (atypical) antipsychotic drugs for the treatment of
schizophrenia. National Institute for Clinical Excellence 2002
http://www.nice.org.uk/pdf/ANTIPSYCHOTICfinalguidance.pdf
2) Duff G. Atypical antipsychotic drugs and stroke.
www.mhra.gov.uk
3) National Institute for Clinical Excellence. Bisphosphonates
(alendronate,
etidronate, risedronate), selective oestrogen receptor modulators
(raloxifene) and parathyroid hormone (teriparatide) for the secondary
prevention of osteoporotic fragility fractures in postmenopausal women.
National Institute for Clinical Excellence 2005
http://www.nice.org.uk/pdf/TA087guidance.pdf
Competing interests:
MDR has been chairman of NICE since 1999
Competing interests: No competing interests
NICE or not we shall see
I applaud the ARM of the BMA for refusing to accept everything is
nice with NICE. We are skilled trained medical scientists and clinicians.
We know what we are talking about in our respective disease areas and we
were treating patients to the best of our abilities well before NICE was
formed. Yes the delegates got the substance wrong but there is a general
feeling among many of my colleagues across several disciplines that it has
far too many powers and inhibits the greatest of medical skills- to
personalise the care to you give to patients, to provide the best
technology and to be innovative. One cap does not fit all in medicine.
We shall see how ageist QALY's are when next week we shall learn the fate
of anti-dementia drugs.
The whole dementia community has been through a terrible few months
waiting for a group who mostly have probably never personaly treated or
even got to know a patient with dementia to decide our patients fate. I
already have patients having their drugs stopped by GP's "because NICE
says so" and subsequently relapsing requiring admission to acute wards. I
dread to think what will happen when this is legitamised and NICE returns
us to postcode prescribing ie., go live in Scotland and Northern Ireland
to get effective treatment. I predict widespread misunderstanding if the
ACD is finalised and patients will suffer. NICE cannot be so naive to
suggest this would not happen and for money to suddenly be diverted to
other aspects of dementia care. This is the way of things. I will feel
great sorrow for all my new patients who will have to pay for their drugs
if, they can afford to do so.
But, NICE needs to be aware from my understanding of what various
professional groups are planning that if these drugs are removed,things
will be at the least be interesting. We are doctors after all and if we
in one of the richest countries in the world face the spectre of not
treating one of our most vunerable and deserving patient groups, shame on
us all. But more shame on NICE if they allow this to happen. We shall
see.
Competing interests:
None declared
Competing interests: No competing interests