In the US, the idea of a Health Visitor is unknown. To me, it’s the first place to refer a parent and child with difficult to sort behaviour. I suspect it is also cheaper and safer.

The important bit to me is ‘cost effectiveness’. It isn’t about either cost or effectiveness alone. While Roche have offered a risk sharing scheme for cost (which wasn’t much less cash and still looked pretty expensive to me), it would have been better had they simply made their product cheaper. In other words, if you have a product which is marginally effective, compensate for this by making it less expensive. If the price is right, it thus becomes cost effective and NICE approved.

Don’t blame NICE. Examine the pharmaceutical pricing instead.

There is one really big problem with this study which hasn’t been addressed, and it’s quite simple. The doctors were asked to report their actions. They were asked what they thought of themselves. There was no outside independent agency assessing the difference between religious and non religious doctors actions.

My reading of the paper is this: religious doctors were less  likely to see themselves as providing deep continuous sedation until death, whereas non religious doctors saw themselves as providing more deep sedation. Sure, religious beliefs may colour many things: but it may simply be colouring how doctors interpreted their actions.

As it stands, this paper simply doesn’t reflect what I see in practice.

Then again, if you are in the US, and you want your daughter to be circumcised – rather, genitally mutilated (and remember – patient choice) –  it is only very recently that the American Academy of Paediatrics have reversed their decision stating that it was ok for doctors to perform a ‘ritual nick’ on girls below the age of consent. Male children, however, can still have ‘cultural’ circumcision on the NHS.

In terms of the ethics of consent, I’m far more troubled by unnecessary operations being done on children.

As they say

“What should happen, for instance, when a 30-year-old man with no relevant signs, symptoms, or family history shows his doctor a genetic test result indicating that he has an elevated risk of prostate cancer? Should his prostate-specific antigen level be measured? An ultrasound obtained? A biopsy performed? What level of risk should trigger further testing? What are the liability risks of not pursuing a diagnostic evaluation? As the number of conditions for screening expands, so will the cost to our health care system and the risk of iatrogenic harm to patients. ”  The answer to the first five questions are ‘we don’t know’, incidentally.

For a long time, I’ve been feeling rather alone in talking about the negative impact of screening tests – it’s great to have company.

The non publication of clinical trials is ethically wrong and fundamentally dangerous – yet legal. This non publication means that a pharmaceutical company can complete a clinical trial, not like the results, disregard them, and carry on regardless. But of course, triallists include doctors who have an ethical obligation to their patients. Doctors must know what non publication is going on.

I am keen to do good research in primary care and over the last decade have been approached by at least two pharmaceutical companies doing what may have been useful research – but who expected me to sign a confidentiality document which would have meant that I was not allowed to talk about the research except with their approval. I said no, but this is legal, and it seems normal – many other doctors have reported the same thing. I don’t depend on research for income – but others do; not just for themselves personally but for their departments.

Why has no politician petitioned for legislation? Why aren’t doctors more upset about this? And why do some doctors STILL see drug reps?

They have examined Referral Management Centres and concluded that they aren’t very good, which was obvious to GPs but lost on politicians. Quite interesting.

What I find more interesting though is what their researchers have to say about GP referrals in general. There seems a belief that variation in referrals are bad and similarity is good. The question of why? doesn’t seem to enter (some GPs may have lots of experience in psychiatry, for example, and are able to handle a great deal of it: other areas may have an older, younger or student population; other practices may have access to an excellent secondary care service that other areas don’t.) And then there is the repeated non evidence based assertion that cancer and renal referrals are often ‘late’, which the evidence doesn’t back up and which I’m getting rather tired of.

But anyway. This report is good in the sense that it examines a non evidence based policy. But it is bad because it doesn’t recognise how complicated the factors that go into making a referral are, or even that there is always a right and wrong answer.

It’s easy to say that

Have had quite a few messages from doctors and nurses basically approving but none of dissent or otherwise from charities.

hmm…