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Paul, you wrote: >suppose that two opposing parties are agreed on a matter of >what they like to call principle. This 'matter of principle' may be the >provision of certain inefficient but high profile and vote catching >treatments. EBM qua Health economics may not get a look in as other real >world considerations will override them. >Furthermore, the same two parties may agree that an efficient and effective >treatment is not vote-worthy and hence consideration of this treatment is >conveniently suppressed. Where is EBM or Health Economics in this? >If you don't believe me that this happens perhaps you might like to ask the >environmental lobby who for many years found that they had no way of >forwarding their case as no party organisation was willing to take it up for >lack of votes in the issue. >OK, so this is basic political theory and perhaps somewhat gloomy. As >practitioners of EBHC we need to be politically aware as sometimes the >'logic' - in the non-mathematical and non-philosophical meaning - of the >case will not sell it to those who hold power. Other projects with more >votes in them may hold front stage and command more funding by our political >masters, who will ration our resources according to their imperatives. We >need to be as persuasive with our arguments and marketing as the drug >companies are with the NHS. with most of which I agree, and as you say, the media often distort and even determine the argument. So we need to be realistic about the constraints which politics (including practice politics, NHS Trust politics, NHSE politics etc etc) place upon us. Nevertheless, the point Mooney was making is about our own attitudes, beliefs and behaviour (constrained as *they* are by our education, social background, acculturation in med school and as junior doctors). Of course several methods of promoting efficiency and the common good are in use, including clinical guidelines and drug formularies. Often these are implemented by a top down process, which clinicians may resent and certainly carry out in a task oriented manner. And, being realistic as much as cynical, giving GPs financial incentives to reduce their prescribing of "wondermycin" is an effective way of reducing its use! What EBHC gives us is the opportunity to clarify the issues with and for individual patients as well as groups of patients, in an active rather than passive manner. If we are doing this, I'd suggest we have also to consider the "common good" interest as well as the patient's. Toby PS thanks for giving me a great idea for the workshop! -- Toby Lipman 7, Collingwood Terrace, Jesmond, Newcastle upon Tyne. Tel 0191-2811060 (home), 0191-2437000 (surgery) %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%