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Can we afford the luxury of evidence-based medicine?


evidence-based


Yesterday, NHS England announced they have cleared the QCovid tool for assessing patients on a range of risk factors, including age, ethnicity, deprivation, BMI and underlying health conditions such as diabetes and heart disease. This has led to an addition of 1.7 million people to the shielding list, including 800,000 people who have not yet had a vaccination.

There is always the worry this will pile work onto GPs. NHS England is responsible for contacting these patients, but as we saw last year (and highlighted recently by the National Audit Office), this could go very wrong.

Regardless, this is a good development. We have known for a long time Covid disproportionately affects BAME people, and those in deprived areas, and hopefully this tool provides a bit more safety for those at risk.

But this, to me, highlights something that has become apparent in the pandemic: that the pre-Covid standards for evidence-based medicine are a bit of a luxury. This might seem heresy. But, in fact, public health chiefs have been practising this on the whole: for example, the original rules on self-isolation were based on common sense with guesstimates, rather than waiting for the evidence. This was undoubtedly the right thing to do.

When public health chiefs have waited on gold standard evidence, it has often led to unnecessary delays. Look at how it took until May of last year to add anosmia to the list of symptoms requiring self-isolation, despite GPs and patients realising this at the start of the pandemic. The same could be said for mandating the use of face masks in public places – something that common sense dictated far earlier.

I do think there has been a delay in terms of approving the QCovid tool, which was first developed in October. In terms of ethnicity data, I agree with Dr Partha Kar, who wrote on these pages last month: ‘The evidence has been there from all corners since the pandemic took its foothold in the UK in March 2020.’ GPs in Greater Manchester, where there is a high proportion of BAME patients, created their own risk scores in May last year. So why couldn’t the authorities get something like this out earlier, when BAME communities were crying out for it?

Of course, we can’t cut corners when it comes to vaccines, or treatments – it goes without saying they need the highest standards of evidence.

But how many lives would have been saved if we didn’t wait for the data on face masks, anosmia and observable risk factors? Sometimes, a rush to action is safer than waiting for the evidence.

Jaimie Kaffash is editor of Pulse. Follow him on Twitter @jkaffash or email him at editor@pulsetoday.co.uk

READERS' COMMENTS [8]

Giles Elrlngton 17 February, 2021 6:21 pm

Many of my patents over the years might have shared the opinion that a rush to action is sometimes safer than waiting for the evidence. I have been professionally obliged to advise that we must wait for evidence, NICE approval, PCT/CCG hospital Trust decisions and so on. I have not always been content to do so, but this has been my duty as an NHS employee.

It is understandable, when faced with adverse health outcome, to rush for action: but we should remember that, while there are budgets for healthcare (this is not about to change), speculative therapy for some, deprives others of evidence based intervention.

Vinci Ho 17 February, 2021 9:17 pm

All I would say is like I always do , the ‘right’ thing at the right time and place could easily be the totally ‘wrong’ thing at different circumstances and vice versa.
The common sense was a face mask is NOT like a medication or operation that can potentially cause substantial harm on side effects . However , given the lethal nature of the pandemic, being pedantic was clearly justified from the outset even though the so called evidence was absent in the beginning.
I had said this many times last 12 months …..

Vinci Ho 17 February, 2021 9:21 pm

In extremely critical moment , it is always a swift choice between cautiousness and audacity .

Just My Opinion 17 February, 2021 9:56 pm

Hmm

Patrufini Duffy 17 February, 2021 11:05 pm

Interesting. But the face mask debacle was not because of lack of evidence, but simply because UK stocks were zero. GOVUK misplanning, couldn’t afford competition with public spending, so they fobbed the public off with delay and misinformation, whilst the East hunkered down diligently, suffocating aerosol spread whilst the UK sadly sunbathed without tanlines, letting the virus bleed everywhere.

David Bush 18 February, 2021 8:47 am

I agree with your comments Ed.
One other danger of EBM is that we dumb down GPs (whose intuition and clinical judgment is what sets them apart from computer algorithms). We must have the freedom to act in what we consider to be the best interewsts of our patients at all times. Not all interventions (or lack of) can be robustly evidenced.
And we must accept that the various QTools are at best rather blunt instruments. The risk of these natty calculators is that we believe them 100% without any critical thinking. We’ve all had patients whose QRisk is modest, but as they are sitting in front of you they are an MI waiting to happen (because, for instance, you treated their Dad for his when he was 40, and his son is like him in every way). Try and evidence that!

Malcolm Ridgway 20 February, 2021 10:50 am

“ Lackof evidence” can be used both ways politically and clinically either to support or refuse a treatment. A modicum of common sense is often what is required. Also evidence is never 100% reliable either way.

Thomas Robinson 20 February, 2021 11:11 am

Evidence comes from academia,and academics are by definition historians,they tell us what has happened,not what is about to,or how to deal with it.
The endless claim to be following the evidence is simply incorrect.There was no evidence as to how to manage an explosive lethal pandemic in 2020 in the UK. The measures taken,were not based on a trial,they were the trial.
The NHS being a chaotic, nationalised,absolutist institution has made historians into directors,unlike more normal rational organisations. No-one is proposing putting Max Hastings in command of British forces in combat despite his undoubted eminence.
So how good are our medical historians.Well the principle of quarantine would have been recognised by a Roman legion.The virus arrived by air,it didn’t swim, or catch a bus.
Presumably some well respected textbook of Public Health advises waiting 13 months into an epidemic before introducing quarantine. That’s how good they are.