- Email: [email protected]
Lord Nigel Crisp
Perspectives
On Reflection Magic is acceptable
Lunch with The Lancet Lord Nigel Crisp
The standard argument against state (or insurer) funding of alternative remedies is that it cannot be right to spend scarce resources on untested treatments of doubtful effectiveness while refusing to pay for tested drugs of proven effectiveness because they are too expensive. Is this fair? Not really. Much orthodox medicine is not evidence based. Many antibiotics have never been tested in randomised controlled trials. Orthodox medicine is often held up as a model of how things work but it is actually far from perfect science. John Bell, professor of medicine at Oxford University, in the UK, observed more than a decade ago that many drugs were discovered by accident, not design, and much treatment was based on anecdotal evidence, not systematic review. The role of social and psychological factors remained little understood. “We need to know what kind of patient has the disease rather than what kind of disease the patient has”, Bell said. Increasing disillusion with conventional medicine has fuelled the explosive growth of interest in alternatives. Complementary medicine has done orthodox medicine a service by reminding doctors of the power of care. The consultations are lengthy, detailed, and personal. What matters to patients are results, not scientific explanations. Magic is acceptable if it accomplishes what is promised. Last month, a scathing report by the UK Parliament’s Select Committee on Science and Technology called for National Health Service funding of homoeopathy to cease on the grounds that it was no better than placebo. Rationalists may celebrate. But doctors faced with surgeries full of miserable patients for whom they can do little may feel differently. Why not exploit placebo effects where we see them? A recent Review in this journal by Damien Finniss and colleagues shows how powerful placebos can be (Lancet 2010; 375: 686–95). These investigators suggest there is a placebo element in all treatment and a dose– response relation, which could explain much of alternative practitioners’ success, given the length of the average consultation. Alternative medicine is said to be a waste of resources. But the orthodox care provided by family doctors is not always cost effective. One practitioner’s placebo is another’s “effective” treatment. As to sucking cash away from proven treatments—should we pay for fertility treatment if we cannot afford to give patients cancer drugs? My instinct is to side with the rationalists. But at the same time I resist their reductionism. The placebo effect may be one of the most underused weapons in the medical arsenal. We should find ways to exploit it.
Lord Nigel Crisp wants to start an argument. The former UK National Health Service Chief Executive, now an independent member of the House of Lords, examined health systems worldwide and determined they need serious rethinking, not just to meet the needs of the developing world, but those of rich countries too. To make his point, he is challenging health professionals about the part they can play and questioning the arrogance of some western aid schemes imposed on developing countries. “Just stop telling people what to do and start listening to them”, Crisp said recently at breakfast in Washington, DC, USA. “The truth is that there is a great deal rich countries can learn from poorer ones.” Crisp developed his view during a 2006 tour of developing countries to determine how the UK “could help improve health and bolster their health workforce”. He was impressed by what he saw in many places and concluded the healthsystem conversation should become more of a dialogue. Many donor countries export not only their funding but also their bureaucracy and their ethos; they usually overlook the innovation and resource savvy occurring in many countries. Crisp gives many examples in his new book Turning the World Upside Down—the Search for Global Health in the 21st Century. He argues, among other things, that health-care staffing structures should strive for a wider base of lower level, community-based and mid-level workers with a smaller proportion of highly trained specialists at the top. In an example of what he calls “training for the job and not just for the profession”, Crisp cites how nurses in Mozambique are trained so that they can do caesarean sections; these nurses stay in their communities rather than migrate out and achieve the same results as physicians. The broader model that Crisp supports not only provides more dependable, communitylevel care but saves money as well. “It’s not that we don’t need the highly skilled people, it’s about proportions. How many of the most highly skilled do you need compared with how many at the middle and how many at the bottom?” Crisp recognises this idea could alarm health professionals and organisations. “You don’t really need to take on the doctors’ trade unions”, he says. “My argument is the most important place to make change is actually in the hearts and minds of individual doctors and nurses.” Crisp hopes to galvanise a movement towards more patient-centred, affordable care. ”In reality it is mostly doctors and nurses who are leading and will lead these changes.” Crisp is optimistic that such change is possible: “We need to foster much more interchange and mutual learning between clinicians and organisations around the world to help make this happen.”
Jeremy Laurance
Nellie Bristol
[email protected]
[email protected]
www.thelancet.com Vol 375 March 13, 2010
885
On Reflection Magic is acceptable
Lunch with The Lancet Lord Nigel Crisp
The standard argument against state (or insurer) funding of alternative remedies is that it cannot be right to spend scarce resources on untested treatments of doubtful effectiveness while refusing to pay for tested drugs of proven effectiveness because they are too expensive. Is this fair? Not really. Much orthodox medicine is not evidence based. Many antibiotics have never been tested in randomised controlled trials. Orthodox medicine is often held up as a model of how things work but it is actually far from perfect science. John Bell, professor of medicine at Oxford University, in the UK, observed more than a decade ago that many drugs were discovered by accident, not design, and much treatment was based on anecdotal evidence, not systematic review. The role of social and psychological factors remained little understood. “We need to know what kind of patient has the disease rather than what kind of disease the patient has”, Bell said. Increasing disillusion with conventional medicine has fuelled the explosive growth of interest in alternatives. Complementary medicine has done orthodox medicine a service by reminding doctors of the power of care. The consultations are lengthy, detailed, and personal. What matters to patients are results, not scientific explanations. Magic is acceptable if it accomplishes what is promised. Last month, a scathing report by the UK Parliament’s Select Committee on Science and Technology called for National Health Service funding of homoeopathy to cease on the grounds that it was no better than placebo. Rationalists may celebrate. But doctors faced with surgeries full of miserable patients for whom they can do little may feel differently. Why not exploit placebo effects where we see them? A recent Review in this journal by Damien Finniss and colleagues shows how powerful placebos can be (Lancet 2010; 375: 686–95). These investigators suggest there is a placebo element in all treatment and a dose– response relation, which could explain much of alternative practitioners’ success, given the length of the average consultation. Alternative medicine is said to be a waste of resources. But the orthodox care provided by family doctors is not always cost effective. One practitioner’s placebo is another’s “effective” treatment. As to sucking cash away from proven treatments—should we pay for fertility treatment if we cannot afford to give patients cancer drugs? My instinct is to side with the rationalists. But at the same time I resist their reductionism. The placebo effect may be one of the most underused weapons in the medical arsenal. We should find ways to exploit it.
Lord Nigel Crisp wants to start an argument. The former UK National Health Service Chief Executive, now an independent member of the House of Lords, examined health systems worldwide and determined they need serious rethinking, not just to meet the needs of the developing world, but those of rich countries too. To make his point, he is challenging health professionals about the part they can play and questioning the arrogance of some western aid schemes imposed on developing countries. “Just stop telling people what to do and start listening to them”, Crisp said recently at breakfast in Washington, DC, USA. “The truth is that there is a great deal rich countries can learn from poorer ones.” Crisp developed his view during a 2006 tour of developing countries to determine how the UK “could help improve health and bolster their health workforce”. He was impressed by what he saw in many places and concluded the healthsystem conversation should become more of a dialogue. Many donor countries export not only their funding but also their bureaucracy and their ethos; they usually overlook the innovation and resource savvy occurring in many countries. Crisp gives many examples in his new book Turning the World Upside Down—the Search for Global Health in the 21st Century. He argues, among other things, that health-care staffing structures should strive for a wider base of lower level, community-based and mid-level workers with a smaller proportion of highly trained specialists at the top. In an example of what he calls “training for the job and not just for the profession”, Crisp cites how nurses in Mozambique are trained so that they can do caesarean sections; these nurses stay in their communities rather than migrate out and achieve the same results as physicians. The broader model that Crisp supports not only provides more dependable, communitylevel care but saves money as well. “It’s not that we don’t need the highly skilled people, it’s about proportions. How many of the most highly skilled do you need compared with how many at the middle and how many at the bottom?” Crisp recognises this idea could alarm health professionals and organisations. “You don’t really need to take on the doctors’ trade unions”, he says. “My argument is the most important place to make change is actually in the hearts and minds of individual doctors and nurses.” Crisp hopes to galvanise a movement towards more patient-centred, affordable care. ”In reality it is mostly doctors and nurses who are leading and will lead these changes.” Crisp is optimistic that such change is possible: “We need to foster much more interchange and mutual learning between clinicians and organisations around the world to help make this happen.”
Jeremy Laurance
Nellie Bristol
[email protected]
[email protected]
www.thelancet.com Vol 375 March 13, 2010
885