NICE supports shared decision makingBMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l1038 (Published 12 March 2019) Cite this as: BMJ 2019;364:l1038
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It is good to be reminded that NICE is committed to principles of shared decision making since this view does not permeate the consultation on 17 ‘evidence based interventions’ and subsequent advice to commissioners from NHS England (1), even though NICE was fully supportive of this exercise, allowing its logo to be used on the documents. The view of NHSE was that variation between CCGs in numbers of interventions being performed indicated doctors were not following established guidelines. Neither the ‘postcode lottery’ resulting from different treatment access decisions made by former Primary Care Trusts nor variation in need were considered as alternatives, so that a universal reduction in numbers of interventions is now anticipated rather than a reduction in some areas and an increase in others.
Economic levers are being used to prevent certain referrals, even though some of the NHSE guidance conflicts with both NICE recommendations (e.g. on the utility of snoring surgery) and guidelines from professional bodies developed through NICE accredited protocols (e.g. breast reduction surgery, where psychological distress is no longer considered an indication). Although there was no previous national guidance on removal of benign skin lesions, NHSE anticipate that the number of such procedures may now reduce by 40% from an annual total of >116k. This is peculiar since NHSE also state that currently removal of a benign skin lesion “is not usually offered by the NHS if it is just to improve appearance” and “there is little evidence that removing benign skin lesions to approve appearance is beneficial”. One wonders why patients are going through these procedures, and if they have been asked about perceived benefit?
The cost saving approach by NHSE disregards the principle that: “At the centre of medicine there is always a human relationship between a patient and a doctor. This is the unchanging core of medical work, despite whatever technical advances are made” (2). In addition, the essence of evidence based medicine as the integration of clinical experience with the best available research information and patient values (3) is undermined if the view of the patient is disregarded. Where will NICE stand as NHSE pursues its stated intention of restricting ever greater numbers of interventions?
1) Evidence-based interventions: guidance for CCGs. NHSE. https://www.england.nhs.uk/publication/evidence-based-interventions-guid...
2) Balint E. The doctor, the patient and the group. Routledge, 1993.
3) Masic I, Miokovic M, Muhamedagic B. Evidence based medicine - new approaches and challenges. Acta Inform Med. 2008;16(4):219-25.
Competing interests: No competing interests