Tuesday, September 08, 2009
Deep thoughts
Was buttonholed over dinner at Hunstanton by an older GP from up North. A John's man, so he must have been OK. But he was very angry about a gang called nice - not the biscuits rather http://www.nice.org.uk/ - who had the temerity to issue directives about what he should and should not prescribe. He claimed first that they often got it wrong, second that they did not balance the cost of the drugs against the savings in hospital costs that might follow from their use and third that young doctors ignored guidance from these people at their peril. Alright for him, well past retirement age and not a big disaster if he got struck off. He went on to claim that crew nice were just of bunch of doctors who couldn't hack doctoring so went in for management - at which they were not much better. A bit like the people that go in for inspecting teachers at work. I was reminded me of a policeman from Scotland, flying a desk near Whitehall, who had explained to me that policemen still doing police work out in the sticks were rather contemptuous of those of their colleagues who plumped for the quick promotion that went with flying desks in the central bureaucracy.
But now sobered up, I start to wonder whether having committees of doctors flying desks in some central bureaucracy is the right way to manage prescription. On the aye side, working doctors are bombarded with all sorts of stuff by big pharma, sticking just to the right side of the rules about presents and hospitality. Then there must be lots of drugs. Is it realistic for a working doctor to keep track of them all? Doesn't it make splendid sense to pool all the knowledge and churn it out digested for the general good?
On the no side, what the elderly GP alleged actually happens is that the work is farmed out to a bunch of committees of these non-working doctors, whose working lives may have been over for some time. Generally speaking the committee is not qualified to rule on any particular drug so it should call for evidence from two or three eminences in the field - it being alleged that at least in one case, the committee adressing the particular drug which interested my informer, claimed to have done this, without actually bothering. However, what usually becomes the guidance for all, is the blending of the prejudices of said two or three eminences, who may well disagree among themselves. In which case one presumes that the guidance has to be a bit vague. Or arbitary. Failing that, the committee dream up something off their own bat. But all this is scarcely pooling knowledge. Doctors are not typing in the results of every prescription and could scarcely be expected to. Collecting systematic knowledge of that sort is a tricky and time consuming business. Notwithstanding, where is the quantitative, objective, evidence-based analysis of the effectiveness of drugs in the field? Is it right that guidance produced in this way should be binding, or anywhere near binding?
There is also the question of vfm. Would we not do better to get all these doctors nice out on the streets doing some doctoring, rather than feeding the central bureaucracy?
From all of which I conclude that this is a tricky area about which I know very little, beyond the fact that we have not suceeded in pleasing all of the people all of the time. Maybe I will feel better able to spout after a spot of the brown stuff from up north. Something the good doctor probably did not go in for, living in Derbyshire rather than on Tyneside. Can't think what the warm beer from Derby is called. I assume that they do do it.
# posted by Jim @ 11:16 AM 
