individual ethic [8]. EBM is concerned with finding out what is the most effective
treatment for a particular patient. However, the treatment that is the most effective
might not also be the most cost effective. A physician who adopted the population
based ethic would be more concerned with recommending a treatment that was
cost effective and in the interests of societ yas a whole rather than just the interests
of the individual patient. Maynard illustrates this tension between the individual
and population-health ethic with an example.
Apurchaser is choosing between two treatments, A and B. Therap yA produces 5
health years ,HY) and therapy B produces 10 HY; leaving aside the problem of how
to define health years, we can say treatment B is the more effective treatment and
should be purchased. This would be purchasing according to the individual ethic,
to do the best for the individual patient and provide the most effective treatment.
However, therap yA produces a HY for £300 and therap yB produces a HY for
£700; given a fixed budget of £70 000 therap yA will produce over 130 more HY
than therap yB. So, if one adopted the population ethic and was concerned with
maximising the number of health years gained with a specific budget, then therapy
Ashould be purchased. Hence, when making decisions as to what care-pathways
to recommend, a value judgement has to be made as to whether the relevant
evidence is that of effectiveness or that of cost effectiveness. As Maynard's example
indicates, with different value judgements different treatments will be purchased.
Aclear example of such a deliberation b yNICE is the consideration of the drug
beta interferon used in the treatment of multiple sclerosis. Sufferers of the disease
argue that the drug is the onl ymedication that prevents relapses, giving them relief
from the symptoms of multiple sclerosis. Sir Michael Rawlins, the chairman of
NICE, issued a press statement in June 2000 saying that other than people who are
alread ybeing prescribed the drug it should not be made available on the NHS. The
reasons for this decision were, on the basis of ver ycareful consideration of the evidence, [beta interferon's] modest clinical benefit appears to be outweighed b yits ver yhigh cost' [9]. This example illustrates two important points. First, patients and patient groups, in this case the MS Society, could have different definitions of an effective treatment from those the standard setting agenc yholds. The MS Societ ydo not agree with NICE's assessment that beta interferon has onl ymodest
clinical benefit'. Second, cost is a factor in weighing up what treatments should be
recommended and in this case it was claimed that the outla yto the NHS was not
justified b ythe benefit it produces for the recipients. In such a deliberation there is
no scientific wa yof answering the question of what this treatment is worth. It is a
matter for societ yto decide what values and priorities are important.
11.13 Putting clinical governance into practice
One of the main ways in which quality will be managed under clinical governance
is through the employment of care-pathways and clinical guidelines. In this section
Iargue that such guidelines could adversel yaffect the interests of the individual
patient. I first give a brief outline of the rationale behind the introduction of clinical
guidelines and then consider how these guidelines can affect patient care.
Part of the process of clinical governance is to assess systematically current
Clinical Governance 245