I remember a Scottish politician saying to me once, ‘If you need to do something in politics, do the right thing, not the popular thing.’ I know that some doctors think that the decisions we make for patients are relatively straightforward. That is, do no harm to your patients and, if possible, do them good. Unfortunately it is rarely that simple. In medicine, as in anything else we do, we weigh up the costs and benefits of our actions. We may not do so explicitly but we do so nonetheless. Every day health professionals decide to devote more time and effort to one patient than another, we agree to review someone earlier, we refer some patients for further opinions and not others, we treat some aggressively and others not so aggressively. These judgements are based on the evidence that health professionals have and their interpretation of that evidence.
   I was thinking of these things as I pondered a recent issue I had to deal with—which groups of people with dementia should have access to acetylcholinesterase inhibitors and memantine in Scotland. In England and Wales, the National Institute for Health and Clinical Excellence (NICE) published its multiple technology appraisal (henceforth the NICE appraisal) on drugs for Alzheimer disease (AD) in November 2006 (http://www.nice.org.uk/guidance/TA111). The National Health Service Quality Improvement Scotland (NHS QIS) looks at NICE appraisals and decides whether they are valid for Scotland. This process is described at the following webref (URL): http://www.nhshealthquality.org/nhsqis/files/NICE%20 Guidance%20process%20.pdf.

For those who are not familiar with NICE appraisals, these look systematically at the clinical effectiveness (i.e. does it work in the routine clinical setting?) and cost-effectiveness (i.e. are the benefits worth the costs, monetary as well as non-monetary?) of health technologies (interventions) and make recommendations for their use within the NHS in England and Wales. Since the NICE appraisal does not apply in Scotland, NHS QIS has been given the responsibility by the Scottish Executive (Government) to look at their validity for Scotland on ‘contextual’ differences such as:

•  The principles and values of NHS Scotland,

•  The epidemiology (frequency, distribution and stage at presentation) of the disease or illness,

•  The structure and provision of services in Scotland, and

•  Other implications for NHS Scotland, e.g. remoteness and rural issues.

• The 3 acetylcholinesterase inhibitors—donepezil, galantamine and rivastigmine—are recommended as options in the management of people with AD of moderate severity only.

• Only specialists in the care of people with dementia should initiate treatment, and carers’ views on the patient’s condition at baseline should be sought.

• Patients who continue on the drug should be reviewed every 6 months by Mini Mental State Examination (MMSE) score and global, functional and behavioural assessment.

• Memantine (which is not an acetylcholinesterase inhibitor) is not recommended as a treatment option for people with moderately severe to severe AD except as part of well-designed clinical studies.

    The NICE appraisal also states that people with mild AD who are currently receiving donepezil, galantamine or rivastigmine, and people with moderately severe to severe AD currently receiving memantine, whether as routine therapy or as part of a clinical trial, may be continued on therapy until it is appropriate to stop. As part of the contextual differences identified for this NICE appraisal, NHS QIS stated that general practitioners (GPs) in Scotland with experience in the care of dementia can initiate patients on these drugs as part of shared care protocols with specialists. This will ensure that people with AD who are eligible in remote and rural areas have access to these drugs.
   It is important to recognize that the NICE appraisal reviewed the original appraisal in 2001 of the 3 acetylcholinesterase inhibitors—donepezil, galantamine and rivastigmine. In the 2001 appraisal, these drugs were assessed as being clinically efficacious and cost-effective for a wider group of people with AD. Therefore, the new NICE appraisal is more restrictive in
its application. Consequently, the NICE appraisal’s recom-mendations were resisted by professional groups such as the Royal College of Psychiatrists and patient groups such as Alzheimer’s Scotland (www.alzscot.org) on the basis that the drugs worked in a wider group of patients than those indicated by the NICE appraisal, i.e. those groups of people with mild, and also severe AD.
   For those in public health and decision-makers who have to make policy decisions, this issue highlights the difference, and difficulties, in making decisions about individual patients and about policies which affect populations. This is to take nothing away from the fact that AD is a difficult and heartbreaking disease for carers to cope with. Watching a person—a husband, a father, a brother, a grandfather or whatever—whose memory and cognitive abilities atrophy while remembering them as they were, is one of the toughest things in life to adjust to. This is quite apart from the demands on carers for the love, care and attention that people with AD need. All this underlines the need for high quality multidisciplinary care for people with AD and their carers.1
   In my view, NICE have gone as far as they can with the evidence they have on donepezil, galantamine, rivastigmine and memantine. Indeed, some have argued that NICE may have gone too far with their recommendations with others stating that the drug issue has meant less discussion on the need for good services, a point made by Pelosi et al. in the BMJ.2 I also think that clinicians and patient groups are missing a point. The issue is not whether these drugs work for AD—there is some evidence that they do—the crucial issue is whether the benefits of the drugs are worth the costs (monetary certainly, but also costs such as adverse effects on patients). I make no apologies for saying that cost-effectiveness must be one of the factors taken into account when deciding how healthcare budgets are used because if we use resources for something that it not cost-effective, then resources will be diverted away from other, more cost-effective, health interventions.
  Of course for some, including journalists looking for an easy story,3 the issue is posed simply in terms of cost. It is not—health policy-makers have to make difficult, but necessary, choices about funding health services on the available evidence. Ignoring the evidence of cost-effectiveness on health interventions would be an abrogation of their responsibilities. So paraphrasing the first paragraph, it is important in healthcare to do the right thing, not the popular thing. On the evidence available to NICE, the NICE appraisal has done the right thing—recommending using the drugs for people with AD who will benefit most from them.

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