Thursday, November 04, 2010

The evisceration of NICE

Polly Toynbee says, "NICE is one of Labour's best inventions". Proof if ever it was needed that NICE has to go. It is is a truth self-evident to all Guardian readers that whatever Polly Toynbee says is automatically antithetical to all right-thinking people. When Polly pontificates we know what side to take.

I don't suppose Polly has ever sat in on a NICE appraisal so as usual she is talking about something of which she has only theoretical knowledge. I have sat in as an expert witness on five occasions. On almost all occasions NICE has got it wrong at first, though sometimes they have managed to correct their view on appeal.

There are several things wrong with the way NICE goes about their work. First: certain members (though not all) of their committees have an extreme prejudice against pharmaceutical companies. They naturally assume that the company is dishonest. I have even seen committee members accuse expert witnesses of being in the pay of Big Pharma and being made to withdraw the assertion under the threat of legal action.

Second: the choice of their own 'expert witnesses' is sometimes bizarre - eschewing people who have researched and written about the problem in favour of local generalists who have no reputation in the field.

Third: their research is done by health economists and 'teenage scribblers' - young graduates who just review the literature without any experience of treating patients or of the great variety of clinical situations that present themselves. These people have no 'feel' for either the disease or its treatment.

Fourth: despite the assertion that 'post-code prescribing' is a great sin, it is actually extremely sensible. For example, there National Guidelines on sickle cell screening for mothers. This is extremely sensible in Camberwell where there is a very high incidence of people of Afro-Caribbean descent, but very stupid in Bournemouth where almost everybody is 'oppressively' white. In Bournemouth, the major health problem is care for the elderly - especially of Alzheimer's disease. The denial of drugs for early cases was much more unfair in Bournemouth than, say, somewhere like Derby, where the geriatricians have so few old people to look after that they look after people in their 50s.

This new government is committed to localism and I thoroughly approve. Having sat through endless reorganisations I am certain the the NHS was best managed in the period prior to 1974 when local authorities could still influence decisions about the provision of services. If you believe in getting the best health service you can in your local area (which is what most people want - they couldn't care a fig for the problems of people in Glasgow who smoke, drink and feast on deep-fried Mars bars - unless they are Glaswegians), then these new moves to disempower NICE can only he welcomed.


Anonymous said...

That's me told then. I asked, you answered. Thanks.

Can I claim a small fee for your use of my comment as a post title?

Terry Hamblin said...

Yes, thanks for the title. You can have a 100% cut of anything I make out of it.

Anonymous said...

This is a very important issue for Americans, who, under the far-left Obama, are hurling head-long into socialism.

As an informed consumer of health care, I am well aware of the dangers of socialized medicine.

As you say, NICE (what an acronym) often doesn't have a clue. For example, they turned thumbs down on most of the modern renal cancer drugs, using studies that showed only modest improvements in longevity.

However, even the casual student will realize that clinical trials are generally done on the sickest patients with the most advanced form of the disease. For there to be any survival advantage is remarkable in this patient population.

I spoke to a nephrologist about the NICE findings. He told me that these new drugs 'revolutionized' his practice. He went on to say that previously, he dealt in palliative care by necessity. Now, he said, he has a variety of options for his patients, some of whom are young, in their 40s and 50s.

(To be fair, I understand that some of these drugs might be used in limited amounts today in the UK. Cold comfort to those who were denied care before.)

This physician practices in California. If he practiced in the UK, he would have the same options to offer his patients.

Why some Americans want to buy into a failed premise is beyond me.

I know Dr. Hamblin is a defender of the system, much like a child defends his alcoholic father against all comers. But that system is broken. Private enterprise does almost everything better than government does.

Terry Hamblin said...

I agree with you about the new drugs against renal cancer, some of which have now become available over here. America has the largest economy still and when measured against it polulation it can afford to spend a lot on health care. The American government alone spends more of a larger GDP than the UK spends on the NHS, so one would expect better outcomes. In fact the USA has a lower life expectancy than the UK and a greater infant mortality. Chronic diseases like diabetes, hypertension and gross obesity are more common. And before you say it is because of the illegal immigrants, it is exactly that factor that drags down out health statistics also.

A free market in health care has the problem that the seller is an expert and the customer is naive. I'm not saying that dostors are as bad a lawyers or second-hand car salesmen, but an awful lot of them are able to retire in their forties. Of course, the third party who pays the bills is going to want some restriction on how his money is spent, and you can guarantee that eventually all healthcare systems will have something like NICE.

What the NHS did wrong was to give NICE complete control over spending. The present government is changing that; spending control will be given back to doctors while NICE will be limited to giving advice.

The major problem that doctors and NICE have to cope with is the fact that pharmaceutical companies will attempt to screw the system for as much profit as they can. There is no reason that those who pay the bill - whether taxpayer or payer of the insurance premium - should give in.

David said...

My knowledge of this subject is like Ms. Toynbee's theoretical, and I can't say that I know that much about the theory either. So I am probably sticking my head into the lion's mouth here. However I can't see anything in your post that would lead me to think that we should not have a national body making decisions on health spending.

I would not dream of questioning your judgement when you say that NICE makes wrong decisions - you were there, and you obviously have a very thorough understanding of the science involved. But surely that's an argument for having a better national body, rather than an argument for devolving decisions to local bodies. Why would we expect local bodies to get it right any more often than national ones?

Regarding the example of sickle cell screening. It is obviously true that there are certain ethnic groups at greater risk, and that this affects the utility of screening, because of the different numbers of true positives and false positives that you would expect in such groups. There are plenty of other diseases where one can identify "at risk" and "less at risk" groups. But surely the sensible thing would be to target screening on the at risk groups, rather than targeting those areas in which they happen to be concentrated. After all if I am in a group that is at particularly risk for Sickle Cell/Tay-Sachs/Thalassaemia or whatever, I will not cease to belong to that group just because I move from Tower Hamlets to Bournemouth, and I cannot see why it would make sense to allow or deny screening simply because my postcode has changed.

Terry Hamblin said...

Local decisions are always likely to be better than national ones because local people know local circumstances best. The previous government insisted on planning to build new dwellings on the flood plain of the River Stour, despite the fact that flooding has become a real problem lately and that local people advised against it.

Screening should be directed at 'at risk' groups, but because of political correctness the previous government was afraid to target it. I would be happy to screen every at risk mother in Bournemouth for hemoglobinopathies. There would be very few.

The people who are best able to judge whether and how a particular patient should be treated are those who hold the local budget - which in future will be the local doctors.

David said...

Local decisions are always likely to be better than national ones because local people know local circumstances best.

I'm not sure to what extent this is really true. National government must presumably know that there are more people at risk of Sickle Cell disease in London than in Bournemouth, and where the flood plain of the River Stour lies. This is hardly secret knowledge accessible only to locals. Of course national bodies may choose not to act sensibly on this knowledge, but then so might local ones.

Terry Hamblin said...

But locals are more likely to listen to local pressure. I have no trust at all for national government. Henry Kissinger said that 90% of politicians give the other 10% a bad name, and he was right. I have even less trust in the EU which is now responsible for 90% of our laws. I don't believe that any one at Westminster or Whitehall could tell the Dorset Stour from the many other River Stours in the UK and they almost certainly think that if Bournemouth is not 9% black then it should be. Dorset police were told that they must recruit 1% from ethnic minorities because national governement doesn't think in units smaller than 1%. I imagine that if the police had followed that instruction then every person from an ethnic minority in Dorset would work for the police!