The political plot thickens

Well I don’t think it’s really a plot, as that would suggest that our lords and masters know what they are doing, sufficient to cook up some sort of plot at all. My last post predicted that I would get the usual “this correspondence is ended” reply from the Dept of Health. After further repetition of the previous letter, here is what I got:

…there is nothing further for the Department to add on this matter.

In other words, “We are not going to answer your questions so you had better get used to not asking them any more”. Do you detect a note of exasperation? Well I have it on extremely good and very senior authority that ministers are getting rather fed up with what they describe as “hectoring and unhelpful” questions from scientists about evidence in health care. Sorry, I can’t reveal my source, but you know you can trust me. Well it’s good news that we are getting them to notice. I don’t think now is the time to worry about how much sleep Earl Howe and Anne Milton are losing, so the message is, don’t back off.

Thus I have broadened the approach slightly. Firstly, there is the Dept of Health’s response to the NHS Future Forum Report. I homed in on a key statement in the summary:

…we will support clinical commissioning groups to make high quality, evidence-based decisions, with information joining up to support integrated care.

What can this mean? If you search for the word `evidence’ in the whole document you get 19 hits, but what I am really looking for is a clear statement that in this brave new NHS, health care providers are expected to follow evidence based practice. It doesn’t say that anywhere. Read it yourself, if you can stand the repetition and boredom. So I asked the Dept of Health. More than two weeks later I got the reply:

You recently contacted the Department of Health to request further information about a paragraph in the summary box on page 14 of the Government Response to the NHS Future Forum that indicates that the Government will ‘support clinical commissioning groups to make high quality, evidence-based decisions, with information joining up to support integrated care’.

This is expanded in more detail later in the Chapter, at paragraphs 3.74 to 3.90: ‘Information and evidence to support high quality integrated care’.  This section considers, in particular, the information and other tools that will support integrated care and the importance of research and innovation for high quality commissioning.

We will publish an Information Strategy in due course, which will provide more detail about our plans to improve access to and the quality of information, including how commissioning can help to improve the collection and use of information and how we will ensure that information systems work together to support integrated care.

I hope this reply has been helpful.

Well of course it isn’t. Is it beyond the wit of the Dept of Health to say something like this?

We expect clinicians in the NHS to follow evidence based practice in patient care.

Apparently it is, because if they did they really would have to close the homeopathic hospitals. I realised that if I asked another question in writing I would have to wait another two weeks for a reply, so decided to phone the press office. They really didn’t want to talk to me, and referred me to the general enquiries desk. I asked to speak to someone about the NHS reforms, but the lady who picked up the phone felt well qualified to answer herself. So I asked whether evidence based practice by individual clinicians formed part of the NHS reforms, and got the usual flannel about how commissioning would be based on evidence. No, that isn’t what I asked, I said, because I am interested in what the Dept of Health expects of clinicians when they are choosing treatments. This went round in circles for a while, touching on NICE guidance, but I pointed out that NICE has not evaluated a great many treatments that are routinely used in the NHS. The lady then referred me to the NHS Constitution, which she said contains the policy I was seeking. Apparently this sets out the standards of evidence based practice that are expected of clinicians. Well guess what, it doesn’t. The word `evidence’ only appears once in the whole 12-page document. It appears on page 6, in this section:

You have the right to expect local decisions on funding of other drugs and treatments to be made rationally following a proper consideration of the evidence. If the local NHS decides not to fund a drug or treatment you and your doctor feel would be right for you, they will explain that decision to you.

Of course, `local decisions on funding’ are not in any way the same thing as whether a doctor is prescribing a treatment with no evidence that it works. It isn’t too long a document to scan through it for any wording that might be relevant to evidence based practice, but there is nothing. I tried to explain that they were getting it the wrong way round. I was not concerned about whether commissioning decisions were based on evidence, I was asking what happens when a clinician ignores a lack of evidence. Naturally, I got for the umpteenth time the DoH mantra that “clinical decisions are for clinicians, and it is not for the Department of Health to interfere”. No, I said, I am not asking for the DoH to dictate what doctors must do, I am just asking what the DoH expects of them. Back to the NHS Constitution, which we now know is useless on this topic. I received a mini-lecture on how clinicians were best placed to decide what to prescribe, which is of course something of a generalisation. I could name a good number of registered physicians who obviously ignore evidence based practice.

At the same time I have pursuing a similar avenue with the General Medical Council.  I kicked off with this question to the media office:

This is a media enquiry on behalf of the charity HealthWatch, of which I am a committee member. I am prompted by the government’s response to the NHS Future Forum Report. The government does not make it clear that evidence-based practice will be a component of the NHS reforms. Indeed ministers insist in correspondence that they will not intervene in clinical decisions, which they leave entirely to clinicians themselves. Could we have a statement please on the GMC’s expectation in this regard? To maintain their registration, to what extent are doctors expected to adhere to evidence-based practice? Will the GMC engage with the government to ensure that evidence-based practice is increasingly followed in the NHS?

I got a fairly quick reply:

I would like to refer you to our core guidance for doctors, Good Medical Practice which in paragraph 3c states that a doctor must, when providing care:

“Provide effective treatments based on the best available evidence”.

Doctors should abide by this guidance at all times in their practice.

My interest was piqued by the phrase at all times. So I fired off this:

I am interested in the phrase “Doctors should abide by this guidance at all times in their practice“. This presumably means that doctors who prescribe treatments for which there is no evidence, such as homeopathy, are in breach of their terms of registration? Please clarify. I should mention that the government’s response to the Science and Technology Committee’s evidence check report agreed that homeopathy is not effective.

Also has the GMC contributed to the government’s consultations on the NHS reforms? In particular has the GMC reinforced the benefits to health outcomes of evidence-based practice?

This time the reply took rather longer – 12 days:

Thank you for your email and apologies it has taken me a while to reply. I wanted to check with our Standards team how best to answer your questions.

I bet he did.

The GMC’s role is not to evaluate the effectiveness of treatments but to set standards of good practice for doctors.

Registered doctors have to apply our guidance to the situations they face and act in the best interests of the patient at all times.

Our guidance does not require doctors to use only evidence based treatments, in any form of medical care, but we do expect doctors to do their best to ensure that any treatment they offer is in the patient’s best interests. This will generally mean that any known risks of the treatment are outweighed by the potential benefits to the patient.

We have not issued any advice about complementary and alternative medicine, as this is not within our remit.

The GMC did respond to the government consultation you mention, but focused on revalidation and education in particular. You can read our response here:

http://www.gmc-uk.org/GMC_response_to_DHE_White_paper_Equity_and_Excellence___Liberating_the_NHS_35892333.pdf

So what about this “at all times in their practice”? It has changed to “do their best to ensure that any treatment they offer is in the patient’s best interests”. I have therefore asked whether prescribing a treatment that is known to be ineffective according to the evidence, is in the patient’s best interest. No reply yet after more than a week. If it ever does appear, I’ll post what they say of course, but I am not holding my breath.

So is all this really so difficult? Not apparently for the Medical Council of New Zealand. Its Standards and Guidelines set out clearly and in detail what is expected of a doctor who practices non-orthodox medicine. For example on page 172:

Any registered medical practitioner who embarks on a mode of investigation or treatment of patients that is not based on evidence of effectiveness must also apply the standards that would be applied to orthodox methods. That requires a history and examination sufficient to make or confirm a generally recognised diagnosis; investigations using generally accepted tests pertinent to the patient’s complaint; a diagnosis that reasonable doctors would make; advising the patient of the orthodox treatment options, their risks, benefits and efficacy, as reflected by current knowledge; and recording all of the above in accordance with sound practice.

It also requires the doctor to demonstrate current knowledge and skills in their specialty; act according to the fundamental values of the profession; provide sufficient information to allow patients to make informed choices without misrepresenting information or opinion. Patients must be told the likely effectiveness of a given therapy according to published and accepted information, not subjected only to the doctor’s individual beliefs.

All this is not just words, and the guidance cites a number of fitness to practise hearings, eg:

…the Tribunal wishes to record that Dr X did not provide any meaningful explanation of the condition of ‘electromagnetic sensitivity’ or any credible reason for having diagnosed (the patient) as having it.

and

… Dr X did convey misleading information to give (the patient) the impression PMRT had a scientific validity it did not have…. Some examples are
a. the authoritative manner in which he gave his successive diagnoses;
b. his use of pseudoscientific language; and
c. his claim to use this diagnostic technique (which he claimed was extensively used overseas) ahead of his peers in New Zealand.

This is all well-established stuff, but in March this year the MCNZ consolidated its position with a very clear statement on CAM. My feeling is that if our GMC adopted such standards a great many doctors would find themselves in front of a fitness to practice panel. Is it therefore surprising that UK doctors will lose the right to regulate themselves? Current GMC guidance on Good Medical Practice has not a single word on doctors who use CAM. I am quite clear on how this should work. It is not for the DoH to regulate doctors. But the DoH pays the vast majority, who work in the NHS, so is a very major stakeholder in medical regulation. The DoH should therefore be engaging with the GMC to set out its expectations for good medical practice. Clearly the GMC is not going to take any initiative regarding unorthodox practice, so it is entire logical for the main stakeholder to drive the process. It would be nice to know how much money could be saved by cutting out evidence-free treatments, but the NHS doesn’t record any useful data except for certain defined areas such as homeopathic hospitals. The problem is far wider than that of course, and embraces a lot of well established practice (eg physiotherapy). The DoH issued a consultation on outcomes a while back, and this really should be the stimulus for collecting such data, but no sign of that so far.

Let me remind you of the purpose of this blog, which is to arm you with some tools to support truth and evidence. Nothing will change if not enough people care, so get writing to your MPs. It is extremely easy these days. Get involved with local and national groups, eg HealthWatch, Sense About Science, and The Nightingale Collaboration. If you belong to a relevant professional body, campaign for evidence based standards. Come on in, it’s great fun!

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One Response

  1. This triumph of political indulgence over evidence is not only a waste of money but also absurd, as illustrated by a French experience whereby the medicine agency (Afssaps) had to issue a national warning to pharmacists and doctors because a homoeopathic company mixed up the labels of two products (both containing no measurable active ingredients)
    Homoeopathic remedies and drug-regulatory authorities Lancet. 2010 23;375:279-80
    Available at http://braillon.net/alain/homeopathic_remedies.pdf

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