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This House Believes... that NICE guidelines on mental health stand in the way of patient benefit

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Chair:
Dr Andrew McCulloch, Chief Executive, The Mental Health Foundation

FOR:
Rob Senior, Medical Director, Tavistock and Portman NHS Foundation Trust, British Association for Counselling and Psychotherapy (BACP)
Steve Shrubb, Director of Mental health Network NHS Confederation

AGAINST:
Dr Steve Pilling, Director, Centre for Outcomes, Research and Effectiveness, University College, London and Joint Director, National Collaborating Centre for Mental Health
Dr Gillian Leng, Implementation Systems Director, National Institute for Health and Clinical Excellence (NICE)

Biography: Dr Andrew McCulloch

Dr McCulloch has been Chief Executive of the Mental Health Foundation since October 2002.

Prior to this, Andrew was Director of Policy at The Sainsbury Centre for Mental Health for 6 years. He was formerly a senior civil servant in the Department of Health for 16 years and was responsible for mental health and learning disabilities policy from 1992 to 1996. He has particular interests in policy development, partnership working, models of mental health care, human resources and public mental health. He has spoken and published widely on mental health issues.

Andrew’s other experience has included being a school governor, the non-executive Director of an NHS Trust, and the Chair of Mental Health Media, a charity dedicated to giving people with mental health problems and learning disabilities a voice. His PhD study related to psycho-social adjustment to old age.

Session report by Jan McGregor Hepburn, BPC

We all had a jolly good row upstairs - ‘This House Believes that NICE guidelines may stand in the way of patient benefit’ was won with a whopping majority; the points being ably and accessibly put by ROB SENIOR, the Medical Director from the Tavistock & Portman. He said that NICE is a political organisation, and that although guidelines are good, their crude application in the field of mental health is dangerous. He thought the advantages were that they provide some more equitable way of rationing, and can stand up to pharmaceutical companies and other pressure groups.

He thought that they had led to improvements in physical care, but wondered if this led to improved outcomes at the individual patient level. They are problematic in the mental health field because there are no neat diagnoses, the clinical picture is usually complex, with various co-morbidities, and treatment decisions are influenced by a lot of variables, including co-morbidity and functional impairment. He said that the problem in this field with RCTs is that they tend to have to have strict exclusion criteria, and try and screen out the variables e.g. therapist difference, which does not really ‘map on’ to psychological therapies of a dynamic nature. As to NICE, he said that therefore small RCTs have disproportionate influence, and that little systematic evidence mans that they are vulnerable to vested interest groups.

The other side of the debate really was a reprise of all that had gone before during the day; that RCTs show that CBT works, and that is what NICE needs to know, and that the guidelines ensure that patient benefit is at the centre of provision. We should not dismiss good research evidence because we don’t like it, or because other things have not been researched.