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Two weeks ago, a Head to Head in the BMJ asked whether you should tell patients about treatments that they can't have. Robert Marcus' resounding “yes” (BMJ 2007;334:826-7 doi: 10.1136/bmj.39171.426690.AD) centred on the premise that doctors owe a primary duty to the patient rather than the state. But how long can this untrammelled advocacy for the individual survive?
Doctors should not “connive with any external agency to deceive patients,” wrote Marcus. The rapid responses agreed, and one of them, published this week as a letter, takes the argument a step further. Patients should not only be made aware of treatments that they can't have, says radiotherapist Michael Williams (doi: 10.1136/bmj.39199.440104.3A), but of the risks of delaying treatments they can have. For patients with cancer, true candour means informing them of the adverse effects of waiting times on their prognosis. Failure to communicate these serious risks to patients, says Williams, has shored up the “current lamentable state” of the UK's radiotherapy services.
Armed with such information, patients can push for changes to the system. This is a good thing, but they need organisation and resources to do so. Does it matter if some of that money for patient groups comes from the drug industry? In this week's Head to Head, Alastair Kent and Barbara Mintzes lay out their opposing views (doi: 10.1136/bmj.39185.461968.AD). My view is that is does matter, that at the very least the nature and extent of any funding should be declared and there must be clear and robust safeguards to minimise influence. (The same is true, of course, for medical journals.) As both contenders point out, the UK's Association of the British Pharmaceutical Industry has recently issued guidance for industry funding of patient groups, but Mintzes says more needs to be done. We'd like to hear what you think, so please cast your vote on bmj.com (http://www.bmj.com/). We'll publish the result along with the best of your comments in next week's BMJ.
Guidance to individual patients is influenced by many factors, not least the clinical setting. This week you'll find two different interpretations of the same data. The hospital based authors of a randomised trial conclude that tonsillectomy in adults with recurrent sore throat is better than watchful waiting (doi: 10.1136/bmj.39140.632604.55), leading to fewer days of sore throat in the six months after the operation. Our editorialist, Paul Little, a professor of primary care research (doi: 10.1136/bmj.39184.617049.80), says the net benefit is unclear because patients are likely to have a sore throat for several days after the operation. Clarity must await longer term follow-up in a larger group of patients.
With the shift in the UK towards practice based commissioning, the primary care view is set to prevail. According to the Department of Health (doi: 10.1136/bmj.39202.341609.DB) nearly all general practices in England are now committed to take on commissioning of hospital and community services. New responsibilities for budgeting across practice populations will make it hard to ignore Jane Wells and Claire Cheong-Leen's call to take an active part in NICE's appraisals of new treatments (doi: 10.1136/bmj.39190.420081.94). Affordability across the population must be discussed as well as cost effectiveness, they say, and NHS organisations must make their voices heard. A doctor's untrammelled advocacy for the individual patient may be a thing of the past.