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Dear Ben, Prioritisation doesn't work so arbitarily like that in England. We have national organisations like NICE who issue Technology Appraisal Guidance (TAG) on certain high cost drugs and medical devices, on the basis of clinical and cost effectiveness. The NHS is legally bound to fund them within 3 months of a positive NICE TAG, but will not fund them if the TAG is negative. But there are lots of drugs and devices that NICE does not pronounce judgment on, because they don't have the capacity and resources to do so. Then this is what happens. You need to remember a couple of things before you read on, because it will give you the context in which we NHS Commissioners operate. Firstly the commissioners are allocated their fixed annual budget (from the beginning of April to end of March the following year). Secondly, the commissioners are statutorily bound by law not to exceed their annual budget by even an extra penny (they have to remain within their allocated resource limit). It's the classical case of Charles Dickens's Mr Micawber in David Copperfield - income 20 shillings; expenditure 19 shillings 6 pence; result happpiness/ income 20 shillings; expenditure 20 shillings 6 pence; result misery. Let's suppose you are a consultant who wishes to use a new drug A or device B which has not been NICE'd. We consider that as a 'service development'. So, you will need to write down a business case and submit it to the commissioners for consideration during the annual prioritisation round. The annual prioritisation round takes place in December/January and all business cases have to compete against each other to be prioritised. The business cases are prioritised against a set of ethical and commissioning principles with criteria and weights (attached to each criteria) and scored. Those that score above a pre-agreed minimum score are prioritised and then sent to a group of local clinicians and commissioners who match the prioritised services against the annual budget available (in an open, transparent and 'Wednesbury' reasonable way). If your drug A does not meet the cut, the commissioners will not fund it that year. Herein, lies the crunch. Ordinarily, if you say you won't fund it, no resident in your local population should have access to the drug/device. The principles of social justice and equity demand that it should be an 'all or none' phenomenon. Lawyers have repeatedly advised us that NHS commissioners can/should take recourse to this action. But politicians are always jittery about the dreaded 'R' word being officially bandied around. So commissioners in the NHS have agreed on a loop-hole (pretty unsatisfactory, in my opinion) to get around this system and keep the politicians happy ie through the exceptional funding route. If you want to prescribe drug A to your patient when it is not ordinarily funded by the commissioners, you will have to prove to the commissioners that your request is truly exceptional. Your request for funding is sent to an Individual Funding Request (IFR) Panel, comprised of commissioners, clinicians, the public and lay members of the Board of the Commissioning PCT, which will decide whether your exceptional funding request merits approval. All off-license/unlicensed funding requests and also funding requests for drugs/devices not approved by NICE TAG's must similarly be sent to the IFR Panel (these are the Panels that Sarah Palin et al refer to the NHS Death Panels, which, by the way, is a completely false description of these Panels). If your funding request is refused by the Panel, you can appeal against the decision, and your appeal will be heard by an Appeals Panel, the composition of which is entirely different from the original IFR Panel. The decision of the Appeals Panel is final. The unsuccessful patient can, however, take the commissioners to court and request a judicial review of the funding decision. Hope you find this useful. Regards, Ash Dr Ash Paul Medical Director NHS Bedfordshire 21 Kimbolton Road Bedford MK40 2AW Tel no: 01234897224 Email: [log in to unmask] ________________________________ From: "Djulbegovic, Benjamin" <[log in to unmask]> To: [log in to unmask] Sent: Sat, 26 March, 2011 14:13:16 Subject: Re: Clinical Decision Making and Diagnostic Error And, of course, we need to add to this, as pointed by Jim Walker, the famous Godel’s proof that we can know something even if cannot prove it… But, Ash, how does this discussion bode to EBMers including your own decision-making when you try to rationally and fairly allocate scarce resources as you have eloquently discussed it on this group on a number of occasions… What do you tell to people who tell you “I know (from my experience) that this treatment works and you are telling me that there is no evidence to fund this therapy”. I am afraid we are coming full circle, and seems to me that we simply do not have any other recourse but to rely on our meager neocortex ( Jim’s “the conscious tip of a fully integrated iceberg”) , at least when it comes to decision-making involving others…And, as I pointed out in my earlier post, justification for this is that rational inferential system (=EBM) is more often right than intuition (although is far from “idiot-proof”…) Best ben Benjamin Djulbegovic, MD, PhD Distinguished Professor University of South Florida & H. Lee Moffitt Cancer Center & Research Institute From:Evidence based health (EBH) [mailto:[log in to unmask]] On Behalf Of Ash Paul Sent: Saturday, March 26, 2011 4:18 AM To: [log in to unmask] Subject: Re: Clinical Decision Making and Diagnostic Error Dear Rakesh, It's interesting to note that Albert Einstein was a great protagonist of the powers of intuition. However, to my mind, his quotes are much more apt for the psyche of the inventor/discoverer, than they are for medics charged with routinely saving lives using proven treatments. Einstein's scientific writings are littered with quotes on the subject: 1. 'I believe in intuition and inspiration…at times I feel certain I am right while not knowing the reason'. 2. 'The intuitive mind is a sacred gift and the rational mind is a faithful servant. We have created a society that honors the servant and has forgotten the gift'. 3. 'The intellect has little to do on the road to discovery. There comes a leap in consciousness, call it intuition or what you will, and the solution comes to you, and you don’t know how or why'. Einstein was, ofcourse, preceeded by the immortal Aristotle who wrote 'Intutition is the source of scientific knowledge'. Regards, Ash Dr Ash Paul Medical Director NHS Bedfordshire 21 Kimbolton Road Bedford MK40 2AW Tel no: 01234897224 Email: [log in to unmask] > ________________________________ >From:Rakesh Biswas <[log in to unmask]> >To: [log in to unmask] >Sent: Saturday, 26 March 2011, 4:37 >Subject: Re: Clinical Decision Making and Diagnostic Error >A quote from Steve Gilman ( posted by Arin Basu in a different context for a >different forum): > >"Much that you learn will be learned at a level below consciousness. Use this. >Even as you guide your thoughts consciously, allow for the intuitive. This >interplay between the conscious and unconscious is where the art of thinking >really blossoms." > >Copyright Steve Gillman. > >Article Source: http://EzineArticles.com/616048 > >Just a lame attempt on my part to summarize this rich discussion. Also the line >marked copyright makes me wonder about its true place in a web based >meta-cognitive future. > >:-) >