I am a ward sister in a hospice and would like to say that I find some of the decisions taken by NICE difficult to understand and, like other people, am beginning to lack confidence in the institute, especially over the issue of drugs to be prescribed by the NHS.

  An example is drugs used in the early stages of Alzheimer's Disease. NICE is not supposed to be making decisions on the basis of cost alone but on clinical effectiveness. As far as I can see, it uses the argument that, statistically speaking, because only a minority of patients benefit from the drugs (albeit a large minority), it is not cost-effective to supply all patients with them—ie the cost is too high because too few patients benefit.

  My view is that this should not be an issue of randomised controlled trials and statistics. It should be about giving drugs to (however few) patients who will benefit—and undoubtedly some do. The most cost-effective way to manage this would be to try all patients on the drugs and then monitor their effectiveness and promptly take those patients off the drugs who are not benefitting from them but letting the rest continue. If this keeps symptoms in check for a longer time for some, then this will benefit the NHS in the longer term.

  This principle should apply to all drugs which are shown to be effective for some patients. It is worth mentioning a similar situation from my own direct experience: we use a lot of drugs to treat symptoms in palliative care on a pragmatic basis—by trial and error. This would seem to be common sense, as individual metabolisms are likely to react differently to any given drug in an unpredictable way. This is illustrated by the fact that randomised controlled trials almost never have a 100% success rate even when a drug is proved to be beneficial for a majority of subjects—there will always be some who benefit and some who don't because no two human beings are unique!

Gay Lee

18 February 2007