Goodbye Clinical Evidence, Hello Celebrity GPs

Governments like change, so when the UK acquired its recent coalition government, it didn’t take a genius to predict that change was on the way for the National Health Service.  The NHS holds a rather special place in the hearts of the UK electorate.  Although the UK media loves to hate it, and most people gripe about it, the bulk of the population have a great affection for what it does.  Few realise that outside the UK most people involved in the medical industry view it with admiration.  Because of its popularity, the incoming government mollified public concern by announcing that they would “ring-fence” spending on the NHS, but then promptly started to change it.

That change was heralded by a consultation on “Liberating the NHS”, which was slipped out before the summer holidays, probably in the hope that few would notice or respond to it before the deadline at the end of September.  It signalled a major change in direction, where control would be moved from the current Primary Care Trusts (PCTs) to consortia of General Practitioners (GPs).

That raises some concerns.  The first is that we don’t train GPs to be managers.  We still train them in much the same way we did a hundred years ago.  So the most likely effect is that all of the managers who get made redundant from PCTs will simply go and work for GP consortia.  And as there are far more of these, it just results in an even bigger set of people micromanaging.

The more worrying concern is what effect this will have on prescribing practice.  The consultation document keeps on trotting out the phrase “clinical evidence”, implying that the NHS and local GP practices base everything they do on good clinical evidence.  It’s a nice theory, and it would be nice to think that those developing this policy change believed in and supported it.  It should be possible – we have a body called NICE (The National Institute for Clinical Excellence) whose job is to promote it.  But as soon as everyone got back from their summer holidays, Andrew Lansley – the new Minister for Health, got out his rusty shears and castrated NICE.  It’s difficult to understand why, but the implications for the NHS and GPs are disastrous.  It’s goodbye to clinical evidence, and hello to whoever can get the most publicity for their favoured drug of the month.

NICE was one of the best ideas in the UK health system.  As well as collecting and disseminating evidence on best practice, it also took on the difficult task of working out the cost effectiveness of a drug or treatment.  In an ideal world, with unlimited money, we’d always give every patient the very best drug there is for their condition.  The problem is that this world is not ideal and money is limited.  With new drugs, particularly the ones that the tabloid press like to brand as “miracle drugs”, a course of treatment that adds twelve months to a patient’s life may cost £100,000, whereas one that adds nine months to their life is only £50.  Which means that someone has to make the hard decision as to which is “value for money”.

NICE did this using a formula to calculate a “Quality Adjusted Years of Life”.  If a drug was deemed to be cost effective, the NHS was allowed to prescribe it, otherwise it was not.  It wasn’t a perfect system, but it did a massively important job, as it allowed the NHS to decide where best to spend its money.  However, in an era, where patients look at healthcare provision as an absolute entitlement, it did not go down well with people who were denied drugs that they thought might squeeze out a few extra months of life.

The result was of this common sense approach was predictable.  When an expensive drug was rejected, a patient somewhere would find a consultant or GP who though it would be beneficial (and there always seemed to be one ready to get their fifteen minutes of fame), and who would support their campaign to be prescribed it.  It was manna to the tabloid press, who would run it as a story of human interest versus Big Brother.  Few UK politicians actually understand the basis of clinical evidence or risk analysis, as most, like Andrew, read politics or law rather than science and have a very sketchy concept of these principles.  Instead, their immediate reaction to any adverse publicity is to cave in to media pressure, throw NICE’s decisions out of the window and go for the photo-opportunity with the patient.

I’m not sure anyone expected Andrew Lansley to take the knife to NICE.  Nor is it obvious why he did it.  Polly Toynbee, writing in the Guardian suggested it may be tabloid pressure and support for big Pharma, whilst Private Eye’s excellent Phil Hammond thought it may be spite at NICE’s less than positive reaction to Lansley’s blatantly populist Cancer Fund.  Whatever it is, it’s difficult to retain any confidence in a minister who is disassembling a body that is respected as a model for clinical evidence around the world.

It’s also difficult to understand where he thinks this will end.  I responded to the consultation, warning of the problem that GPs would face if they were to take charge of making these decisions.  GPs aren’t trained to manage, and they certainly aren’t trained to resist the might of the national media.  Every patient that can persuade a publicist to take up their case now has the power to expose their GP to the nation as an unfeeling bastard – a medical scrooge who will be portrayed as being more interested in maximising their income than giving their patients access to the drugs they allegedly need.

Carl Elliott, in his book “White Coat, Black Hat“, gives some vivid examples of how pharmaceutical companies recruit and use doctors as Key Opinion Leaders to promote their most profitable drugs.  Whilst I suspect most of Pharma would prefer the return of NICE, as that’s a regime they know and understand, they’ll be getting out the cheque books and seeing who they can usefully add to their payroll.  Ironically, the Sunday Times newspaper recently published its guide to Britain’s Top Doctors.  It’s the next step forward on their peculiar love of league tables to categorise what the chattering classes should be aspiring to.  I wonder how many of the entrants in future years will gain their place based on their willingness to prescribe whatever their patient wants, inaugurating a new generation of celebrity GP?

By removing the ultimate authority, Mr Lansley has opened up a Pandora’s Box that has the potential to bankrupt the NHS by putting prescribing practice into the hands of tabloid editors.  If you’re planning to become ill, make sure it’s at the start of the financial year.  For with an evidence-free policy like this, where media exposure will determine the NHS’ drugs bill, anyone falling ill later in the year may find themselves limited to little more than bedside manner and aspirin.