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Doing evidence-based medicine? How NHS managers ration high-cost drugs / David Hughes; Shane Doheny
Social Science & Medicine
Swansea University Author: Hughes, David
Accepted Manuscript under embargo until: 10th May 2020
This paper describes how British NHS managers enact a form of evidence-based medicine (EBM) as they consider whether to fund high-cost drugs for individual patients. It is based on observations and audio recordings of meetings of a Welsh Individual Patient Commissioning Panel. Panel deliberations re...
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This paper describes how British NHS managers enact a form of evidence-based medicine (EBM) as they consider whether to fund high-cost drugs for individual patients. It is based on observations and audio recordings of meetings of a Welsh Individual Patient Commissioning Panel. Panel deliberations represent a hybrid discourse that links decisions to scientific evidence, but also takes account of organisational and lifeworld pressures. Discussions typically begin with a verbal review of the latest evidence concerning drug “efficacy” for the type of patient referred, but this empiricist repertoire quickly shifts to a procedural repertoire that effectively limits access to funding to patients with exceptional characteristics. “Exceptionality” is determined, not by considerations of social worth or deservingness, but by whether the patient falls within a subgroup shown by randomised controlled trials to gain more than average benefit. A mechanism that limits the numbers qualifying for expensive interventions thus continues to be connected to evidence. Nevertheless a third contingent repertoire concerned with such matters as political interventions, legal challenges to decisions, and the moral misgivings of panel members, may also enter discussions. Panel members’ attempts to “do” EBM usually combine these three discursive repertoires without great difficulty, but the paper describes instances when tensions between them surface. Cases where drugs appear likely to bring benefit but exceptionality is absent, and those where expensive interventions will bring only a few months of extra life, were among the areas that caused panel members to reflect upon the rationality of their decision-making procedures. Controversy about individual funding requests has intensified in recent years with critics questioning the evidential basis of some decisions, and major policy reviews being undertaken in both England and Wales.
Evidence-based medicine; individual patient funding requests; rationing; clinical effectiveness; NHS
College of Human and Health Sciences