Helen Macdonald: Too much medicine—not a NICE business

helen_macDavid Haslam, chair of the National Institute for Health and Care Excellence, anticipated a difference of opinion as he addressed his audience at the Preventing Overdiagnosis conference last week. He knew that the audience would bring it up eventually, so he went head on into the controversial NICE guideline that lowered the threshold for cardiovascular risk prevention strategies in July—and more specifically made around one in four UK adults eligible for medical treatment with a statin.

He wrote in the conference programme that the dilemma posed by over and under diagnosis crossed “all manner of practical and ethical minefields.” I imagined that Haslam, as a medical leader of a major medical institution, would be in the midst of that minefield with his sleeves rolled up. But it seemed that his role at NICE simplified things, and instead he tiptoed uncomfortably around the edge. He said that the remit of NICE was to analyse the science and cost effectiveness only. The practical and ethical minefield that the guidelines created seemed not to be a NICE problem.

But if it’s not NICE’s problem, which organisations will help doctors and patients through the minefield of over and under diagnosis? It reminded me of being a junior doctor searching for a team to accept a new admission, and returning to find written in the notes: “Many thanks for asking me to review patient X, we have seen, examined, looked at the XR/ECG/bloods etc. Impression: this is not a cardiology (our specialty’s) problem.” It might have been an accurate answer. But it never felt that satisfactory because the patient’s problem was unresolved. And there were no suggestions about where to turn next.

What would an entry in the notes from NICE read? “Many thanks for referring the UK population for an opinion on whether statins or other strategies might make them a bit healthier. It is clear that there are ethical and practical problems here. But having examined the evidence, statins are not a cost effectiveness problem.”

If NICE cannot address the ethical and practical pieces of the puzzle, shouldn’t they have called on others for further opinion? Its opinion on cost effectiveness does not seem to have satisfied those who live and work in the minefield.

Helen Macdonald is the analysis editor, The BMJ.

Read Duncan Jarvies’s blog: Preventing Overdiagnosis 2014—I am not legion