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The End of the NHS

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The popular view of the National Institute for Health and Clinical Excellence (NICE) is that it’s a mean, penny-pinching government watchdog set up by Labour to deny sick people access to life-saving drugs. So the news that the government will be stripping NICE of its power to determine which new drugs should be available on the NHS has been broadly welcomed. NICE wasn’t expecting the move, though perhaps it should have been. The Daily Mail, predictably enough, is ecstatic, claiming a ‘victory for patients’ and heralding an end to ‘the ordeal of tens of thousands of patients being denied life-extending drugs every year’. Avastin all round!

Except that just because NICE won’t be responsible for drug rationing from 2014, that doesn’t mean rationing will go away. Someone will still have to make the hard decisions about which drugs are, and which drugs are not, affordable for the NHS. Despite its miserly reputation, NICE has recommended that the NHS make use of 83 per cent of the 380 drugs and treatments it has evaluated to date.

NICE doesn’t recommend a drug if the evidence for its effectiveness is shaky, or if its price is out of proportion to the benefit it confers compared to existing treatments. In the case of Avastin (bevacizumab), NICE doesn’t recommend its use for metastatic colorectal cancer because the treatment would cost on average £88,364 to provide a patient with one additional year of life; NICE’s cut-off figure is £30,000.

Taking the responsibility for deciding what should and what should not be prescribed on the NHS away from NICE means shifting it somewhere else: the Tories’ plan is to dump it on doctors. As the health secretary, Andrew Lansley, has explained, ‘We will move to an NHS where patients will be confident that where their clinicians believe a particular drug is the right and most effective one for them, then the NHS will be able to provide it for them.’

What this means in practice is that GPs will have to decide which patients should be denied the best treatment in order to balance the books. The main reason NICE was set up in the first place was to do away with ‘postcode prescribing’. Doctors are warning that returning the decision-making to more than a hundred local GP consortiums is going to see postcode prescribing return with a vengeance.

Being given the responsibility for rationing healthcare isn’t going to do GPs any favours, either. Alan Maynard, a professor of health economics at York, is quoted in the BMJ as describing the future of GPs under the new scheme as ‘a little anarchistic and uncertain’. ‘The government is quite clear that it wants to give clinical autonomy back to the medical profession,’ he says. ‘If I were a doctor I would be quite wary of that.’

That’s putting it mildly. As soon as GPs take over the purse-strings they are going to be subject to intense lobbying from individual patients, patient groups, specialists and, of course, pharmaceutical companies. And they are going to be put directly in the firing line of public opinion. How many local GP consortiums are going to be able to withstand the tabloid onslaught that will follow a decision to deny cancer patients life-extending treatment? And what will happen to their other patients if they blow the budget on a handful with high-profile diseases?

One GP commenting on the news in the medical press writes: ‘kiss goodbye to the benefit of the Dr-Patient relationship and hello confrontation and bitterness.’ Another says: ‘The truth is slowly dawning on everybody. GPs will be held to account for all NHS rationing from now on.’ The way doctors feel about becoming the bad guys could have far-reaching consequences. Britain’s GPs work under a nationally negotiated contract with the NHS. If NHS work is made difficult and stressful enough, it’s always possible that they will choose not to renew that contract, taking the NHS down with them.

Comments on “The End of the NHS”

  1. echothx says:

    Far more patients suffer from doctors lack of familiarity with, and failure to follow NICE guidelines than suffer from lack of expensive drugs denied by NICE. There’s still a desperate need to disseminate evidence better and improve clinical decision making. If money were invested in this, it may not necessarily save NHS money, but it could vastly improve patient care. I wonder why that’s not in the economic analysis? jonathon tomlinson abetternhs.wordpress.com

  2. echothx says:

    r/e GP rationing. Whether we should be responsible for all NHS rationing on the grounds that we’d be better at it, reminds me of another type of painful cut. In a debate a few years ago it was argued that surgeons ought to perform criminal amputations under Sharia Law because they’d be better at it than executioners. It seemed to me to take a while for the protagonists to get to the point that amputating criminal limbs was the problem, not who was doing it. (Mary Midgely “Trying out one’s new sword” is a useful reference)

  3. nmj says:

    A shame NICE isn’t also being stripped of its powers to ‘legislate’ on the management of the illness known as ME/CFS.

    http://tinyurl.com/385qzaf

  4. Robin Durie says:

    Thanks for this blog, Emma. I can’t believe how little genuine opposition Lansley’s ideologically driven destruction of the NHS is meeting with.

    Of all the reasons why denuding the regulatory power of NICE is a ridiculous policy – re-introduction of the post-code lottery, an end to evidence-based decisions about prescribing patterns, rendering GPs vulnerable to the concerted lobbying of the pharmaceuticals industry, etc – perhaps the worst is how regressive this decision is.

    Figures show that in economically deprived areas, there is a lower number of GPs per capita of the population than in more affluent areas. At the same time, despite all of Labour’s best efforts, health inequalities have risen during their period in office. Couple all of this with the fact that people from deprived communities are less able to lobby successfully, and it becomes apparent that this move will leave those potentially most vulnerable to the postcode lottery even worse off.

    And let’s not stop making the basic, simple, point that clearly eludes the Mail & all its fellow travellers – whatever the merits or demerits of this decision, the basic fact is that the resources for drugs in the NHS remain just as finite as they ever were. Decisions about which drugs should be made available will still have to be made.

  5. Janet Low says:

    On the grounds that it is easy to centralise power, but not at all easy to centralise wisdom, making some changes to NICE will be a useful thing. Ideology and rhetoric, unfortunately, flourish when wisdom is scarce and power is concentrated.

    ‘Evidence based’ blah blah is one of those phrases that will be a big relief to see deflated. This doesn’t mean that due attention to the right kinds of evidence, reason and logic will vanish – unless you think the country is peopled by weaklings and idiots.

    The concentration of power in the hands of NICE and their insistence on a certain idea of evidence has led otherwise thoughtful people to construct randomised controlled trials on psychotherapeutic interventions. Madness. A redistribution of power in accordance with wisdom seems to be a much better idea, and if that means that local resources are the result of local contests, at least it will be easier to find the people responsible, and get on and do something rational about it.

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