Returning from Pulse Live today I still have the encouraging words of Prof David Haslam ringing in my ears. The chair of NICE showed his true GP colours when he declared that NICE produced ‘Guidelines, not Tramlines’, that patient choice was an integral component of each guideline they produce, and it was especially important in relation to risk modifying treatment – such as the new lipid modification guidance which is currently in consultation.
However, Prof Haslam also conceded that people tend to gloss over some of the fine details of any new guidance, and head not only for the summary, but often for the summary of the summary – choosing to focus on the hard facts of treatment thresholds or target ranges rather the greyer areas of informed joint decision-making. This is understandable, but it needs to change.
I took part in the debate on how we treat our elderly patients – are we filling them up with harmful and unnecessary pills through disease-mongering, or should we be more concerned about age discrimination and fight to make sure the aged don’t miss out on all that modern medicine has to offer? At the end of the debate, two things were clear to me.
The first was that most geriatricians are inherently decent people who care for their patients, making it nearly impossible to pick a fight with them even when you are on opposite sides of an argument.
The second was that no-one in the room wanted to deny patients treatment on the grounds of age, but all were concerned about the potential harms of too much treatment. Had the motion been, ‘This house believes it is really difficult to get the balance right between overtreating and undertreating the elderly’, we could have all nodded wisely in agreement and finished early for coffee.
Prof Haslam chaired the session, and he challenged us to come up with real, workable solutions that might help. I managed to think of two: it wasn’t difficult, since they have been on my mind for some time. I think they would be easily workable and could make a real difference, so I hope you will forgive the indulgence of reproducing them here.
While we may not need to change the actual guidance that NICE produces, we need to change how they are written. It should be impossible to skip the small print and miss out the role of informed patient choice.
Choice should be written throughout the guidance, penetrating deeply into the summary, and even the summary of the summary: it needs to be impossible to avoid. NICE might say, for instance, that statins are not cost effective below a CVD risk of 10%, but they then need to give a large range where choice is the biggest factor influencing prescribing.
For instance, the guidance could say that above 30% most patients would want to take a statin, and should be encouraged to do so, but that between 10 and 30% some patients will want to consider treatment, but that this depends on personal values, willingness to accept risk etc. To follow the guidance, therefore, a doctor would have to encourage an informed discussion about treatment, rather than necessarily start the treatment.
This would influence factors outside to NICE which never the less depend on it – in particular the Quality and Outcomes Framework. At present, for example, there is a QOF marker relating to primary prevention of CVD – where there is a 20% or greater risk the criterion is not about having an informed discussion, but about starting treatment – you don’t get to tick the box unless a statin has been started. Change the wording of NICE guidance and this would have to change too: doctors would have to take part in informed decision-making, but there would be no pressure towards, or against, prescribing.
Of course, there is always the option of exception reporting for QOF – which brings me to my second point. We must get rid of the phrase ‘informed dissent’. Dissent is the language of deviance and disobedience – is this really the behaviour of a patient who chooses not to take risk-modifying medication? To simply change the word ‘dissent’ for ‘choice’ would transform the process of exception-reporting and enable doctors and their patients to make better decisions.
It can’t be that hard, surely?
Dr Martin Brunet is a GP in Guildford and programme director of the Guildford GPVTS. You can tweet him @DocMartin68.