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Doctors or Resource Allocators?

A recent survey by Myeloma UK, and reported on the BBC website, suggests that many doctors do not tell patients about drugs that may be beneficial and which are licensed in the UK. The trouble is that the drugs have not yet been approved by NICE and so may be difficult to obtain on the NHS. This seems to suggest that something is wrong with the way in which NICE functions with respect to licensing and that doctors are in some way complicit.

There are (at least) two particularly difficult elements of this problem. First, decisions about the way in which resources in the NHS are allocated must be made and they must be made carefully – on the basis of the best evidence available. There are certainly significant issues about the way in which NICE operates but these do not undermine the need for decision-making about which treatments or procedures receive funding (see also: The process of evidence gathering and consultation takes time — it is clearly this that is part of the problem. One possibility is to allow drugs under review by NICE to be funded during the review process. However this would likely mean that patients receiving a drug would be taken off it in those cases where the drug was deemed to be not worth being funded. A second possibility is to align the licensing process more closely with NICE’s appraisal so that, say, a drug would be licensed only once a NICE appraisal had been conducted. This may help to some extent but it would not decrease the time that patients have to wait for new drugs.

The second difficult element of this problem involves the role of the doctor. We typically take doctors to have very special and important obligations to care for and act in the best interest of patients. If there is an increasing lack of confidence in the medical professions it is very likely the result of failures in our confidence that this is the case. As is illustrated by debates about advertising in medicine, there is something deeply problematic about doctors with too much of an eye on the finances, particularly when it involves the prospect of cheaper, possibly less effective treatments. As far as possible it seems advisable to separate the doctor from the resource allocator. Doctors should in this sense be patient advocates rather than institutional representatives. This is not to suggest that doctors should be unaware of the kinds of issues that arise in resource allocation nor is it to deny the importance of these decisions. Instead it is to suggest that roles of physician and resource allocator should be kept as distinct as possible.

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3 Comment on this post

  1. I think the extent to which it is desirable to separate physicians from resource allocation. While certain decisions (such as the evaluation of new treatments) are clearly difficult to make at the bedside, the everyday work of a doctor involves frequent decisions in which resource availability ought to take a part.

    A junior doctor might be thought to make almost none of these ‘big’ decisions, however they do make frequent decisions about small tests and treatments. Many such decisions will take into account the need ‘to be on the safe side’. Do I tick the box for liver function tests for the third time this week for Mr Smith, or in the absence of new symptoms assume there is no need? Well, I don’t anticipate any problem with them, but on the other hand, what’s the harm? It might just save me a dressing down from a consultant who wants me to read his mind and order this test just to be sure.

    It’s a problem similar to that of antibiotic use. You might give your patient antibiotics ‘just to be on the safe side’. However emerging resistance, and the problem of Clostridium Difficile infection have both changed this mindset, and there is increasing awareness that antibiotic use carries a risk of harm to both the individual and the population. The sustainability of health care affects individuals as well as populations. In caring for individual patients, doctors ought to give some consideration to financial ‘risks’ in their risk benefit analyses.

  2. It’s also worth noting that the argument here is not coming from patients alone. The data cited by Myeloma UK here was from a study sponsored by Celgene, who hold the license for Revlimid, the drug being discussed here as a ‘significant advance’. That’s just a single instance of the insidious pressures being exerted on bedside decision making.

  3. Thanks for your comments Bernadette. You are right to point out the complexities involved in separating out the ‘clinical’ from the resource allocation decisions. My view is that we should push things to be separate as far as possible but that there may be practical limits on the extent to which it can be realised. There are various practical things that can help I think, mostly to do taking the responsibility for the resource decisions away from the clinician. So for instance, having clear, specific, resource-driven guidance of the sort developed by NICE is one option.

    The antibiotics example that you give is an interesting one becasue there are both clinical and resource elements to it. In so far as the over-prescription of antibiotics increases resistance there may be definitive clincial reason against prescribing. The ‘just to be on the safe side’ reason is more tricky and may be where the guidance is needed – the idea would be to try to adjust or ‘relevantly constrain’ judgements with guidance so that clincians who tend to prescribe for this reason too often are limited by the recommendations.

    On your second comment: I’m very aware of these sorts of general issues (though not in this case). Herceptin springs to mind!

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