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NICE row pits patient choice against economic reality

By Daniel Cressey

NICE showed its appetite for making headlines again last week when it provisionally ruled inhaled insulin was too expensive to be made available on the NHS.

The outcry was predictably furious just as it had been when a draft appraisal restricted use of Alzheimer's drugs to patients with moderate disease.

Both these recommendations sparked intense debate among GPs, with some keen to provide patients with the latest drugs, while others pragmatically argued limits have to be set in a resource-strapped NHS.

Dr Neil Munro, a GP in Claygate, Surrey, and associate specialist in diabetes at the Chel-sea and Westminster hospital, London, believes NICE has 'gone too far' with restrictions on new therapies.

'There is a worrying trend in the UK to lay blocks in front of every new therapy that comes and one of the most effective blocks is to use arguments of cost-effectiveness,' he said.

Dr Peter Tasker, a GP in King's Lynn, Norfolk, was also critical of the decision on inhaled insulin. 'My reaction was one

of sadness. It is an enormous shame patients are being denied a new method of giving insulin,' he said.

But has Government rhetoric on 'choice' created false expectations, leading patients to believe they can demand any treatment they desire, such as Herceptin, whatever the evidence of clinical benefit?

In the case of inhaled insulin, NICE argued that the drug 'could not be proven to be more clinically or cost-effective than existing treatments'.

Yet patient advocacy groups are not convinced and want NICE to place more weight on patient preference.

Bridget Turner, head of health care and policy at Diabetes UK, said 'in some cases' patient choice should trump cost-effectiveness. 'One person's cost is not another person's cost ­ the weight they attach to that in QALYs is not necessarily based on individuals.'

The NHS has always been used as a political football but recent meddling from ministers, such as Health Secretary Patricia Hewitt's comment that no patient should be denied a drug on cost alone after a trust refused to fund Herceptin, is causing conflict between economics and patient demand.

Professor Richard Baker, director of the department of general practice and primary health care at the University of Leicester, said: 'If something can't be economically justified it can't be justified. The issue is how to have a discussion with patient representatives rather than "everyone have it if you want it".'

Dr Stuart Eastman, a GP in Amesbury, Wiltshire, agreed: 'I think patients are being misled. They are told they can have anything they want but in reality that's not how it works.'

Dr Chris Dunstan, a GP in Woking, Surrey, and member of the NHS older people's task group, warned: 'We've seen many drugs hailed as the best thing since sliced bread that then turn out not to be. If patient choice is unlimited the NHS will not survive.'

The conflict between choice and financial reality can cause problems for GPs trying to explain why patients can't have the new 'wonder drug'.

Dr Neil Statham, a GP trainer and a GP in Newport, Gwent, said: 'I try to persuade the patient of the logic of the situation. If all else fails and it's threatening our relationship I do give way at times.'

It remains to be seen whether pressure from specialists and patients' groups will force NICE to back down.

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