BMJ  2007;335 (18 August), doi:10.1136/bmj.39308.477870.BD

Editor's Choice

Editor's choice

Why this unholy trinity?

In this week's letters pages, Oliver Dearlove takes Roger Jones to task for his recent editorial on the future of the medical profession in Britain (doi: 10.1136/bmj.39303.684236.3A). According to Jones, "The Shipman, Bristol, and Alder Hey enquiries, and a litany of errors, shook the foundations of public trust and professional confidence." But where is the evidence for this, asks Dearlove? The foundations of public trust remain apparently unshaken: in poll after poll, doctors still top the league tables of public esteem while politicians languish at the bottom.

So how has Jones's unholy trinity emerged as a shorthand description of the problems afflicting the British medical profession in the late 20th century? They seem poor candidates for the burden they've been asked to bear. Take Harold Shipman: had he been an engineer rather than a general practitioner, nobody would have thought his serial killing reflected badly on his profession even if he had used some of the tools of his trade in the murders. Similarly, the Alder Hey inquiry centred on the activities of a single rogue pathologist. Together, they seem as far from representative general practitioners and hospital consultants as it's possible to be. Bristol was singled out for its atypicality: twice the mortality from open heart surgery on children under 1 year, compared with other English centres.

If we're determined to divine a general lesson from the recent past, it may be that governments, like people, should be careful what they wish for. The Bristol, Alder Hey, and Shipman inquiries were all initiated by the Blair government in its first term, when the vilification of doctors was at its height. In that administration's second term the focus shifted to what should be done about "underperforming" doctors, which led inexorably to revalidation and the new contracts and massive pay increases of Blair's final term. One would need a heart of stone to witness this playing out of the law of unintended consequences—and not be moved to tears of helpless laughter.

But to give credit where it's due: the Blair government's first term also saw the birth of what is now the National Institute for Health and Clinical Excellence (NICE), which has profoundly changed the way that England and Wales evaluates health interventions—for the better. NICE has survived the first legal challenge to a decision since its inception, over drugs to treat Alzheimer's disease (doi: 10.1136/bmj.39307.630347.DB). A year ago in this journal, Robin Ferner and Sarah McDowell considered how individuals and groups with special interests might seek to outflank NICE (BMJ 2007;332:1268 doi: 10.1136/bmj.332.7552.1268), and in this case they were well represented. Responding to the High Court's decision, the Alzheimer's Research Trust was "devastated," a drug manufacturer called the guidance "disgraceful" and "morally reprehensible," and the chairman of old age psychiatry at the Royal College of Psychiatrists was "astonished that the NICE process has been found to be rational and without perversity in this case."

So bravo to NICE for sticking to its guns, and bravo to the High Court for backing its decision. Countries without their own NICE are looking admiringly at the one servicing England and Wales, but the need for adequate resources, a very thick skin, and strong protection against political interference can't be underestimated. NICE's next difficult decision is over drugs for blindness (doi: 10.1136/bmj.39307.507558.DB).

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This article has been cited by other articles:

• Jones, R. H (2007). Stance is worst type of spin. BMJ 335: 465-465 [Full text]  
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