A professional session took the form of a debate facilitated by Mr Nick Ross, the broadcaster and writer. Short presentations were made by four speakers: Sir Alan Langlands (chief executive, National Health Service Executive), Mrs Mary Baker (of the Parkinson's Disease Society), Dr James Johnson (chairman, joint consultants' committee, British Medical Association), and Mr Trevor Beswick (regional pharmaceutical officer, South West regional office, NHS Executive)
Sir Alan Langlands told the audience that priority setting was a fact of life. It had always occured in the National Health Service and happened at every level. Sir Alan had no problems with using the word "rationing", but he assured the audience that the NHS had no specified maximum or minimum amount of resources that could be spent per patient. Resources were allocated to get the maximum benefit for patients and priority setting was a beneficial and necessary process.
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Sir Alan Langlands: people have a right to expect fair access to the NHS |
Challenges
On future pressures, Sir Alan said that there were significant challenges that would place greater demands on the NHS in future. One of these was the fact that patients had rising expectations of the service. These expectations could be met in future through NHS Direct, and through the internet and digital television.
"Many patients in the future may be happier to click their mouse before seeing their GP," said Sir Alan.
Another challenge was changes in the size and age structure of the population. Over the next decade the NHS expected to provide services for an extra 100,000 people aged 85 years or more.
A third challenge was new technology and new drugs. "Advances in genetics offer the possibilty of helping us shift more from a ‘diagnose and treat' towards a ‘predict and prevent' service," Sir Alan said. New drugs could be expensive but could have the potential to reduce the need for hospital admission.
Taken together, Sir Alan told the Conference, those challenges added up to extra pressures for NHS resources. But there was still a lot of scope for using existing resources more efficiently. One way of achieving this was making better use of pharmacists' skills to improve patient care and using medicines more rationally.
Turning to the second question on how to set priorities, Sir Alan said that prioirity setting occured at three levels. Ministers set national prioirities and targets for improvement, health authorities and primary care groups assessed needs and decided on treatments and services, and individual clinicians decided the type of clinical treatment and priority for individual patients.
Legitimate local variations
Sir Alan said that this approach to priority setting would result in legitimate local variations. Most services were available in most places, but there are variations in access to some services.
But the Government believed that people had a right to expect fair access. And to support local decision making, it was working in several ways with the professions, managers and the public to try to ensure that clinically effective services were provided on a consistent national basis.
It was doing this by introducing national service frameworks as a guarantee of quality and access for patients, by establishing the National Institute for Clinical Excellence to promote clinical and cost effectiveness, and by reviewing the arrangements for assessing the cost-effectiveness of new technologies, including drugs, and encouraging their appropriate use.
Further steps
Within these national arrangements, clinicians and health authorities would decide on treatments and services. But the NHS Executive was taking two further steps to make sure that such decisions reflected local need. First, local NHS performance would be monitored and unacceptable variations would be challenged. Second, good practice in the process of setting local priorities would be identified and disseminated.
"In the NHS, it is everyone's responsibility to ensure that the resources available are used to best effect," Sir Alan declared.
Turning finally to new drugs, Sir Alan said that advances in pharmacogenomics were pushing back the frontiers of what was possible.
"We can look forward to drugs that are tailor-made for individual genetic profiles. We need to ensure that the most cost-effective drugs are taken up speedily while the least cost-effective drugs are phased out," he said.
The NICE would assess new drugs and issue authoritative guidelines on their cost-effectiveness. Sir Alan said that the NICE would not shirk thorny issues, and believed that the NHS and the public would welcome clear guidance.
Concluding, Sir Alan said that no better model than the NHS had been found for adapting to change and development and for making the best use of available resources to meet the demand for health care.
Mr Ross asked Sir Alan why there seemed to be a growing sense that the NHS "can't cope". He added that British people had a "sentimental attachment" to the NHS, but that their attitudes were changing as they travelled abroad more. Was it possible that the people could lose heart with the NHS and that that could lead to a swing in political attitudes?
Sir Alan accepted that there were areas in the NHS where improvements could be made. However, the NHS was good at dealing with the management of new technology. It was not a sponge that soaked up taxpayers' money; it contributed to the economy of Britain as a whole by getting people back to work.
Mrs Baker told the Conference that the patient organisation she represented (the Parkinson's Disease Society) had, over the years, underestimated the role of the pharmacist. She had come to realise that patients with chronic diseases tended to remain with one pharmacist and that such patients trusted their pharmacist. The Parkinson's Disease Society had not realised this but was now trying to use pharmacists' services more.
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Mary Baker: building bridges between science and society |
Patients wanted an early referral - if a referral was necessary - to a doctor who had a real interest in their illness.
Patients wanted a better telling of their diagnosis, inasmuch as it was essential that the doctor understood how the diagnosis of a chronic disease would affect the patient.
Patients wanted continuity of care when dealing with health care professionals and they wanted to participate in the management of their conditions.
Pharmacists had a role in providing support to the patient in the understanding of their medicines. Better understanding led to better compliance, said Mrs Baker. Patients also needed clear, understandable information leaflets.
Mrs Baker told the Conference that patients with chronic diseases had an important role to play in the management of their condition. Often new drugs came along, but sometimes their doctors had not heard of them so would not prescribe them. Mrs Baker saw a role for disease societies like the PDS in keeping doctors informed about new treatments.
The mission of her society was to bring about dialogue between science and society. There was also a need to extend research into the quality of life issues and economics issues surrounding chronic diseases.
Mrs Baker said the voluntary organisations could help build bridges between the power bases of central government and medical and social services.
"We need to combine the knowledge and clinical observations of the doctors with the experiences of those people living with chronic neurological illnesses on a daily basis," she said. It was a question of bringing together the two experts: the doctor with his medical knowledge and the patient with his life experiences.
Mrs Baker added that, in order for service providers to deliver appropriate and cost-effective care, it was important that they listened to the voluntary organisations.
Mr Ross asked Mrs Baker how important pharmacists could really be to patients with chronic diseases when their time, like doctors' time, was limited.
Mrs Baker said that patients had told her that they received a level of support from pharmacists that was far beyond what they would normally expect and that they never felt rushed.
Whatever the political climate, clinicians were ethically obliged to do what was best for each individual patient, Dr Johnson told the Conference.
He explained this in terms of the philosophical principle of deontology, which was about individual freedoms and justice. This was at odds with another philosophical principle, namely, utilitarianism, which was about doing the most good for most people. The two principles were not compatible and could not be applied to the same issue.
QALYs
The best example of utilitarianism in health care was the concept of quality adjusted life years, or QALYs. Here, treatment would be given to a patient who would gain the most QALYs as a result of it. For example, a 20-year-old man with a hernia might gain 50 QALYs after treatment, whereas an 80-year-old with stomach cancer might only gain half a QALY after treatment. To whom, therefore, should treatment be offered?
This approach might be considered to be not very humanitarian, but the National Health Service as a whole had to take a utilitarian view.
Individual doctors, however, were likely to take a more deontological view. They were obliged to do the best for the patient that was in front of them and not consider the patients they had seen before.
Turning to the subject of national service frameworks, Dr Johnson said that there was a danger in these inasmuch as they tended to move attention into the realm of "politically correct" diseases, such as breast cancer. He knew of one hospital which had a dedicated breast cancer dietitian. This, in his view, was nonsense. Breast cancer patients did not need a dedicated dietitian, but this was what was happening. Resources were being removed from some areas and put into services for patients with "politically correct" diseases, he asserted.
Why, he asked, was no one interested in peripheral vascular disease. That condition could result in patients losing their legs, yet there was no national service framework for it. It was not a politically correct disease.
He warned that doctors should be nervous about co-operating too closely with rationing. Many rationing decisions were political and doctors should not pretend that such decisions were theirs.
"Doctors are not agents of the state," he said. "I hope we never lose that."
Stalinist?
In response to a question from Mr Ross, Dr Johnson suggested that applying utilitarian principles across the board was close to approaching the Stalinist view of "bumping people off".
Mr Ross accepted that decision making was complex, but it was the doctor's job to juggle that complexity. Surely, Dr Johnson was not suggesting that the NHS was Stalinist.
Of course, the NHS was not Stalinist, replied Dr Johnson. Doctors had budgets which they had to allocate in the best way possible in a utilitarian way. But it was not possible to be utilitarian when dealing with individual patients. Individual doctors had to treat each individual patients without thinking about what treatment had been given to other patients.
Pharmacists and pharmaceutical services had a lot to offer in helping to meet priorities, and current National Health Service developments would provide exciting and important challenges for the profession, Mr Beswick told the Conference.
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Trevor Beswick: need to integrate pharmacists into care teams |
On waiting lists and times, Dr Beswick said that efficient and effective inpatient treatment depended on rational and effective medicines management, much of which was ensured by the work that pharmacists undertook within clinical teams. He said that he knew of new initiatives concerning the use of patients' own drugs and streamlining discharge medication processes which were proving to be valuable.
Turning to primary care, Dr Beswick said that, in seeking to support general practitioners, most primary care groups were looking to obtain pharmaceutical advice. The pharmaceutical advisers appointed would have key roles in managing the unified budget, he said.
He went on to describe a number of development projects.
Work in Staffordshire had shown that community pharmacists were able to contribute to the improved control of antihypertensive treatment. Pharmacist run GP-based clinics in Knowsley and St Helens, which concentrated on medicines review and lifestyle advice, had demonstrated beneficial improvents. In Cornwall, community pharmacists had been able to make interventions in asthma treatment which influenced prescribing positively. In Wiltshire, work had been under way to encourage appropriate referral between GPs and community pharmacists and to tackle upper respiratory tract infections and appropriate use of antimicrobials. There had also been various projects on repeat dispensing which had indicated the potential for better management of medicines and cost savings.
Another Government priority was cancer. Dr Beswick said that the quality of care of patients was improved through treatment monitoring and dose preparation by pharmacy-based cytotoxic reconstitution services, which also reduced the risks from occupational exposure to cytotoxics by doctors and nurses.
Dr Beswick added that there was a need to realise the benefits of integration of pharmacy into care teams. This had been accomplished in considerable measure in secondary care and was now increasing in primary care.
He told the audience: "If you were to ask me what the unique contribution of our pharmaceutical input was, I think it has something to do with being able to provide a thoroughy evidence-based, non-partisan contribution."
But while making that contribution, one was faced with the issue of clinical freedom. How could one deal with the wishes of an individual clinician to meet the wants and needs of an individual patient in the context of the NHS wanting to focus its resources and efforts on clinically and cost-effective interventions that met its priorities?
"That debate," said Dr Beswick, "is often boiled down to the regrettable protrayal of a fight between the hard-hearted bean counter and the compassionate shroud waver."
But doctors should have a responsibility towards the individual and the population, and the way to work towards this was to include all players in the discussions on quality, cost and prioritisation. Mr Beswick added that it was pertinent to note that the National Institute for Clinical Excellence planned to consult widely on its guidance.
After the formal presentations, Mr Ross invited the audience to take part in the discussions.
Dr Gordon Appelbe (London) said that he had been disturbed by what he had heard. Ultimately, low priority amounted to rationing and withholding treatment. The Government was about to introduce human rights law into legislation and he wondered whether this would prevent the withholding of treatment. Would the law require more money to be put into the NHS?
Sir Alan replied that this was a hugely complex issue for the NHS which would impact on a number of areas.
Miss Nicola Gray (Manchester) expected that the future would see an explosion in private health insurance which would have a huge impact on the NHS.
Sir Alan said that evidence showed the issue of private insurance was not a significant one in the UK, although he accepted that some parts of the population were more dismissive of the NHS than others. He said a tension was emerging between making the NHS more responsive and making people use it more responsibly. He agreed that much needed to be done to ensure consistency of service.
Autonomy
Professor Nick Barber (University of London) pointed out that there was currently a huge trend towards patient autonomy. Nothing would stop it, and he wondered whether the NHS could survive it.
Mrs Baker said that she did not want to see a National Health Service where patients dominated and "called the shots". Patients did not have the knowledge. But health care professionals needed to work in partnership with patients. She was concerned that there was often a perception among patients that they "ought" to have something rather than "need" to have it.
Mr Ross asked Sir Alan how much he was prepared to see pharmacists being given a greater role.
Sir Alan replied that there were not enough doctors and nurses, so using all the skills available to the NHS to their maximum effect and providing more access to the service was important. He supported extended roles for pharmacists.
Mr John D'Arcy (National Pharmaceutical Association) asked for the panel's view on NHS Direct.
Dr Johnson replied that doctors were worried about NHS Direct and saw it as a threat to the family doctor system. But the fact was that patients liked it. There was a message for GPs that they were not currently providing what patients wanted.
Sir Alan said the cost-effectiveness of NHS Direct was not yet proved.