Healthcare, politics and the NHS
pharmafile | November 24, 2010 | Feature | Research and Development |Â Â Academy of Medical Sciences, Les Roes, NHS, clinical trials, clinical trials governance, evidence-based medicineÂ
I have just participated in a consultation by the Academy of Medical Sciences on the regulation and governance of clinical trials in the UK.
The viability of the clinical research sector is of course a hot topic, and the outgoing government took various steps to try to shore up a declining situation. It occurred to me that whether British politicians are willing to support healthcare R & D will necessarily be driven by their attitudes to science and to evidence.
Do rational politicians exist?
During the general election campaign I asked all the local candidates the same question: What should primarily drive healthcare policy, evidence of efficacy and safety, or patient choice? It was one of several questions designed to clarify whether they were rational thinkers. Out of seven candidates announced at the time (another one appeared later), only three replied, from the three main parties.
The Labour and Liberal Democrat candidates came across as clearly rational, and supportive of evidence based medicine. I thought this was surprising on the part of the Labour candidate, as it was his party that invented patient choice as a key driver in the NHS.
The Conservative candidate seemed to have learned his politics at the knees of experts. In summary, his rambling reply said that the situation was much more complicated than I was suggesting, and that local needs and choices would have to be part of the mix. A classic case of fence-sitting.
A surgical strike?
So now we have a new government, and a few bits of healthcare policy are emerging from the two-party horse trading. Overriding everything is the amount of money that the NHS will have to save. As usual, the axe seems likely fall on management and administration, a sop to the popular view that the NHS is top-heavy with managers at the expense of clinicians. Well if you compare it with other major corporations, it isn’t. The published figures show that it actually is below average for the number of managers compared with workers, and thus is under-managed, not over-managed.
But how the figures are generated is interesting, because of the ways in which roles are flagged as clinical or management. It is likely that some people with clinical qualifications are actually doing management jobs, usually without management qualifications, yet are counted as clinicians not managers.
It’s well worth watching, and if what I suspect is true it’s a blatant abuse of the statistics, which means that there may well be more managers than we think. But I predict that because they are clinically qualified their jobs will be safer.
Making the right decisions…
The question therefore is, will the new government take a rational view of all this? The cost-effectiveness of paying higher salaries for clinical qualifications, and then not using those skills, merits examination, I would have thought. Ensuring that the NHS has top quality management should save a lot of money, but I am not very confident that the right analysis will be undertaken. The reason for this digression is that it exposes a poor regard in some quarters of the health service for rational thinking.
…and therapeutic ones
Money could also be saved by a more rational policy on treatment options. The outgoing government’s most influential innovation in healthcare was in my view NICE. Like it or loathe it (and many voters do), at last there seemed to be real political will to evaluate therapies and other technologies scientifically.
There can be no doubt that NICE has produced a large volume of appraisals and guidance, mostly of good quality (the back pain guidelines did however generate a lot of flak for recommending chiropractic and acupuncture on quite weak evidence).
At least as importantly, the concept of measuring outcomes has been brought into the public and political arenas. The problem is that the public, and probably a lot of politicians, do not understand how outcomes are set against costs, to enable recommendations.
Many ordinary people think that NICE only worries about cost. Negative appraisals from NICE have brought forth vociferous protests from patient groups, even to the extent that the government has overruled NICE and made certain drugs available. Thus when it comes to the crunch, politics rules over science.
This is rather worrying. Most readers will be aware of the huge dispute over the advice to government on drug abuse, with ministers effectively saying that they are right and the science is wrong.
A poor attempt to explain
I suspect that one factor in all this has been the general public’s rather poor understanding of what science is. Could it be that, to damp down the reaction to NICE appraisals, the idea of patient choice was placed in centre stage? Did the last government give up on attempts to explain what NICE was doing, and instead tell everyone that they should not worry as all that mattered was what they wanted, whatever NICE might say?
No, that’s too simplistic, and in any case I don’t think the government seriously tried to explain how NICE worked. But it still seems to be a remarkable anachronism to have cost-effectiveness and patient choice pushing in opposite directions.
Testing the realpolitik
The patient choice dogma culminated in the idea of patients being given their own budgets for their healthcare. A pilot for this was set up before the election, and the Department of Health says it will run to completion in 2012.
The objective is to test the hypothesis that personal health budgets improve health outcomes. However the project website says it is under review by the new administration, so all this could change.
On the one hand, there is good evidence that organisations that measure what they do, and base decisions on real evidence, are more successful than those who rely on the latest business gurus (those people who write the books you see in airport shops). On the other hand, it all depends on whether the personal health budgets methodology can actually test the hypothesis effectively. Some observers are worried that government schemes like this are usually set up to fulfil a pre-ordained policy.
That’s just what happened in Northern Ireland when a pilot was set up to roll out alternative medicine to primary care – it is widely cited as providing evidence of effectiveness, when its design could never have tested that.
So is there hope?
I am not quite as gloomy as I seem to have looked so far. I did see previously that the new government insists that outcomes are paramount in healthcare. If ministers want to push that through, they have a big job on. While evidence based medicine is arguably the greatest achievement of science, it is far from the norm in the NHS.
There is not much rigorous evidence for a good deal of physiotherapy practice, for example.
The widely quoted BMJ Clinical Evidence website states that only 13% of commonly used treatments have high quality evidence. This is of course a misleading statistic, as it’s the proportion of clinical practice not the number of treatments that matters, and it’s well documented that between 50% and 98% of the former is evidence based, depending on the specialism. Better than 13%, but it can improve.
Sadly the last 13 years have seen a growing propensity to disregard science and to encourage a wide range of evidence free ‘therapies’. Some members of parliament have been particularly active in this, notably Peter Hain and David Tredinnick in the Commons, and the Countess of Mar in the Lords.
Scientific politicians under attack
The tragedy of the recent election is the further erosion of science among politicians. In the last Parliament we had 86% of MPs with some sort of background in science, and we now have 71 per cent.
One of the brightest and best was Dr Evan Harris, active on the Science and Technology Committee. He was unseated by an unholy alliance between extreme religious and anti-science interests. For these reasons I am not yet convinced that we will see a more evidence based approach to healthcare policy, because it may be that the skills needed are scarce among politicians. Just the same respect for evidence that is essential for therapeutic choices, applies to management decisions, so will the selection of the 4,000 redundancies be driven by cost-effectiveness data or by popular opinion?
Time for a change (well they asked us to vote for it)
The new government has the opportunity to draw a line under the ‘New Age’ woolliness that has pervaded much of the NHS, and to commit to a health service with science and evidence as its foundation. This would mean a commitment to active participation in research, with clinicians enthusiastic in the generation of new knowledge as a key part of their jobs.
They will only do this within a culture that rejects the fudging of figures for political reasons, and respects the achievements of modern medicine.
Will this happen? I am not sure, but am sure that physiotherapy departments are not going to be reduced to the level of their practice that is evidence based.
Les Rose is a freelance clinical scientist and medical writer. www.pharmavision-consulting.co.uk
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