Monday, 12 November 2012

Why being NICE ain't always right.

The Party loves to control and one of its more limp organs of control is called NICE which stands for the National Institute of Clinical Excellence, sorry comrades, it actually stands for the National Institute of Health and Clinical Excellence (NIHCE).

Several of the team at ND Central have been disturbed recently by pharmacists refusing to dispense some prescriptions which we have issued. We here at ND Central have been critical of certain groups of pharmacists but on this occasion we cannot fault them for they were spot on right.

So here is a quick look at the "game" that GPs have been playing with NICE advice and more importantly the safe treatment of our patients. Remember NICE is always right, if you believe the Party and must always be followed by a "good" well appraised doctor so our appraisers tell us. Let us tread backwards through the mists of time and how we as a group of Northernshire GPs' have treated our patients over the last few years and the Party's role in it.

A few years ago a group of drugs called statins were launched amid claims that these were the new aspirin although in contrast to aspirin at less than a £1 a month these cost a minimum of c £20 a month.

Our radical pharmacist "friends" at the local Soviet said yes, they could be life saving, but they were too expensive, and so quoting the great prophet Keele said that for a simple unenlightened, uneducated GP to prescribe them on the basis of scientific research alone was a mortal sin that would severely harm the patient (PCT drug budget).

The prophet's wisdom applied for all time until the first holy statin patent for the evil drug Simvastatin expired and these drugs became almost as cheap as Aspirin when the followers of the great prophet decreed that all should be prescribed them until they came out of their back passage, which in quite a lot of cases they literally did.

This combined with widespread muscle aches which pharmacists never see made the followers of the prophet happy for these drugs were now doing good in contrast to the great evil of harm they did to patients (PCT drug budget) when they were expensive.

When we were young grunts we were taught that the management of high blood pressure was once a diuretic, then a beta blocker, then a calcium channel blocker and then, only after hospital admission, an ACE inhibiter. All worked but some were cheap and others expensive.

Another group of (politically) inspired zealots called the NICE(ntralization) guys decided that in contrast to those grunts who taught us we should prescribe the more expensive drugs first for what was once cheap, cheerful and worked is now decreed to be ineffectual and not NICE.

Hence another new prophet called the NICE guy, he of shiny teeth and no medical knowledge, decrees and dictates that Amlodipine and ACE inhibitors are now first line blood pressure treatment and should be prescribed by all true believers of the NICE guys (or else you won't get revalidated by his new political organs) for to disregard a good shaft by a NICE guy (your appraiser) is now heresy.

However, as practicing doctors we do not do NICE guys, we didn't go to their type of school, and people not just here but across the world realized that the once expensive and evil not to be prescribed statins are not that safe because someone had not actually done the real experiment with a statin and given it to a really large group of patients over several years outside of a clinical trial (until it became cheap).

And that was before the latest MRHA advice which means that once again following one set of guidelines to prescribe statins and amlodipine will dump GPs in some nasty smelly brown stuff.

As doctors we were once trained to evaluate research and form an opinion for an individual patient. The Party does not like this so it expects all of us to slavishly follow their advice via the prophet and the NICE guys blindly which could harm our patients but that is not important as long as Party diktat is followed.

Now as simple GPs we have had guidance from the NICE guys and the prophet Keele contradicted by the MHRA. So what do we as simple GP grunts on the ground do?

Continue to prescribe NICE blood pressure treatment and drop the statin?
(Our appraisers would not have us do so to ensure continuing compliance with Party policy via NICE guidelines).
Or keep the NICE statin and drop the NICE blood pressure treatment?
(Our appraisers would not have us do so to ensure continuing compliance with Party policy via NICE guidelines).

Or do we prescribe a not NICE once more expensive alternative statin (Atorvastatin) which is now cheap as its patent expired earlier this year? We do not know if by doing so if we may later have the same problem as with Simvastatin. Why?

Up and to now Atorvastatin has been prescribed restrictively in the UK due to its cost only, not its effectiveness, and we do not yet know if the MRHA identified problem with an interaction between simvastatin and amlodipine is to be an all statin drug class effect as opposed to an individual statin drug effect.

The drug industry have already seen an opportunity and are recommending that we prescribe more expensive statins that have not been prescribed widely and so as yet have not been outed as possible problem medications due to interactions.

Tick box medicine is not the way forward for whenever NICE and other bodies (bullies) publish guidance it is invariably out of date. Medicine is a dynamic subject and grunts on the ground have to respond to changes long before NICE can even get out of bed and put its myopic glasses on to read long outdated research, analyse it and after political and economic santisation published its retarded "guidance".

The grunts on the ground need a degree of autonomy not Sovietization via NICE for sometimes we notice things that we send into the MHRA that turn out to be true long before the true pattern emerges.

However they do eventually listen and act. And then we all have to change tune again which means once again explaining to patients why being NICE is actually being wrong and nasty for it wastes everyone's time except the NICE guys and the prophets.

For none of them ever see patients just like the politicians whose every wish they comply with.

Praise be to the Party for its plethora of guidance which if you slavishly follow will always dump you as a doctor, your staff and worse your patients in it. Whatever every happed to professional freedom of thought and expression when balanced with good training and ability?

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