Journal article 976 views 154 downloads
Doing evidence-based medicine? How NHS managers ration high-cost drugs
Social Science & Medicine, Volume: 235, Start page: 112304
Swansea University Author: David Hughes
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DOI (Published version): 10.1016/j.socscimed.2019.05.009
Abstract
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...
Published in: | Social Science & Medicine |
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ISSN: | 0277-9536 |
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Elsevier BV
2019
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URI: | https://cronfa.swan.ac.uk/Record/cronfa50302 |
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2020-10-19T13:01:52.1826787 v2 50302 2019-05-10 Doing evidence-based medicine? How NHS managers ration high-cost drugs f1fbd458e3c75d8b597c0ac8036f2b88 David Hughes David Hughes true false 2019-05-10 FGMHL 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. Journal Article Social Science & Medicine 235 112304 Elsevier BV 0277-9536 Evidence-based medicine; individual patient funding requests; rationing; clinical effectiveness; NHS 1 8 2019 2019-08-01 10.1016/j.socscimed.2019.05.009 http://dx.doi.org/10.1016/j.socscimed.2019.05.009 COLLEGE NANME Medicine, Health and Life Science - Faculty COLLEGE CODE FGMHL Swansea University NIHR 2020-10-19T13:01:52.1826787 2019-05-10T04:51:54.4729210 Faculty of Medicine, Health and Life Sciences School of Health and Social Care - Public Health David Hughes 1 Shane Doheny 2 0050302-17052019135752.pdf 50302.pdf 2019-05-17T13:57:52.4100000 Output 271896 application/pdf Accepted Manuscript true 2020-05-10T00:00:00.0000000 Released under the terms of a Creative Commons Attribution Non-Commercial No Derivatives License (CC-BY-NC-ND). true eng |
title |
Doing evidence-based medicine? How NHS managers ration high-cost drugs |
spellingShingle |
Doing evidence-based medicine? How NHS managers ration high-cost drugs David Hughes |
title_short |
Doing evidence-based medicine? How NHS managers ration high-cost drugs |
title_full |
Doing evidence-based medicine? How NHS managers ration high-cost drugs |
title_fullStr |
Doing evidence-based medicine? How NHS managers ration high-cost drugs |
title_full_unstemmed |
Doing evidence-based medicine? How NHS managers ration high-cost drugs |
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Doing evidence-based medicine? How NHS managers ration high-cost drugs |
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f1fbd458e3c75d8b597c0ac8036f2b88 |
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f1fbd458e3c75d8b597c0ac8036f2b88_***_David Hughes |
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David Hughes |
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David Hughes Shane Doheny |
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Social Science & Medicine |
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Swansea University |
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0277-9536 |
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10.1016/j.socscimed.2019.05.009 |
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Elsevier BV |
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http://dx.doi.org/10.1016/j.socscimed.2019.05.009 |
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description |
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. |
published_date |
2019-08-01T04:01:43Z |
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11.021648 |