|Implemented in this survey?|
In August 2006, the National Institute for Health and Clinical Excellence (NICE) announced its twelfth work programme, which outlines those interventions that it will be assessing over the coming months. The programme reflects in part NICE's relatively recent commitment to assessing public health interventions, and also includes a focus on attempting to improve mental health care, which is an area that has recently attracted increasing attention in the general health policy debate in the UK.
The main purpose of NICE is to assess interventions for their clinical effectiveness and cost-effectiveness. NICE then issues guidance on whether or not an intervention ought to be made available
in the NHS in England and Wales. When NICE announces that an intervention is clinically and cost-effective, the NHS is required to make that intervention available throughout the country. Therefore,
NICE guidance is meant to reduce the possibility that interventions that are available in one part of the country will not be available in another part of the country, an occurrence that is often
termed 'postcode prescribing'.
Assessment of public health programmes and clinical interventionIn the twelfth work programme, the Government has announced that, in addition to a number of clinical interventions, NICE will also be assessing a number of public health programmes (although, in the case of public health programmes, the guidance will only apply to England, because Wales has its own arrangements in place).
The public health programmes that NICE will assess include those appertaining to the prevention of smoking in children and young people, guidance in schools on sensible alcohol consumption and on sexual health behaviour, guidance on physical activity in the workplace, schools and the community, and guidance in schools and residential care institutions on the promotion of good mental health. Some of the above interventions and programmes are intended to target the growing problem of obesity.
The clinical intervention assessments that will be undertaken in the twelfth work programme are many, and include Idaraparinux sodium for preventing stroke, Abatacept and Rituimab for treating rheumatoid arthritis, Alteplase for acute ischaemic stroke, cochlear implants for severe to profound deafness, and continuous positive airway pressure for sleep apnoea.
Single Techology AppraisalAs part of the twelfth programme, the Government has also announced that a number of interventions will be assessed through the new, relatively quick Single Technology Appraisal (STA) process. The STA process was agreed between the Government and NICE in November 2005, and can be used to appraise single interventions for single indications. The STA process has essentially been introduced so as to create a faster timetable for assessing drugs, due to concerns that patients were being denied potentially very beneficial drugs for too long in the longer appraisal process.
The objectives are to attempt to reduce postcode prescribing and to improve clinical and cost-effectiveness in service delivery by the NHS following centrally-issued guidance on the appropriate use of a number of clinical and public health interventions and programmes.
Positive NICE recommendations are mandatory. That is to say that when NICE concludes that an intervention is clinically and cost-effective, NHS organisations have to find the resources to provide that intervention. Acting of negative recommendations is not mandatory, but if a general practitioner prescribes an intervention that is, according to NICE guidance, not cost effective, s/he is expected to have a good reason for not taking heed of the guidance.
Patients and the public, most health care providers, the pharmaceutical industry
|Degree of Innovation||traditional||innovative|
|Degree of Controversy||consensual||highly controversial|
|Structural or Systemic Impact||marginal||fundamental|
|Public Visibility||very low||very high|
As noted above, NICE has been quite controversial at times over the years, and the degree of impact that it has on the NHS in the grand scheme of things is, at best, very marginal. Politically, it is very difficult for it to issue negative recommendations. Moreover, the methods of economic evaluation that it recommends are highly suspect. But the basic 'ethos' underlying NICE - i.e. assessing whether the 'benefit' of health care inteventions and programmes are worth their 'costs' - is, I believe, a worthy one, and I'm hopeful that NICE will improve its methods and will remain 'in business' for the forseeable future.
The policy and practice of assessing interventions in NICE has been ongoing since NICE was created in 1999. There has in more recent years, however, been more emphasis placed on public health programmes, due to such factors as the growing concern with the problem of obesity, smoking etc.
|Implemented in this survey?|
A concern with introducing national standards of care and reducing postcode prescribing was expressed by the New Labour Government soon after it was first elected in 1997. NICE was an institution created by the Government relatively soon after (in 1999), to attempt to address some of these concerns.
The Government was obviously very supportive of NICE, and faced no strong opposition in parliament when NICE was established.
Many within the NHS, although supportive of removing costly and not hugely beneficial interventions from the system, face problems in implementing NICE guidance for at least two reasons. First, most of the recommendations have been positive, which means that many health care organization have had to find from somewhere the resources required to fund new 'cost-effective' and yet 'cost-increasing' interventions, and many organizations have struggled in this respect. Second, doctors deal with 'individual' patients, and have in some circumstances found it difficult to 'deny' patients access to an intervention based on guidance calculated from 'population' statistics (this situation is exacerbated by a media that generally portrays the 'rationing' of any interventions as 'NHS cuts', which makes negative decisions very difficult to make from a political perspective). Where patients have been denied access to treatments, they can and have gone to the courts, and the 'legality' of negative recommendations from NICE is not altogether clear.
The pharmaceutical industry has always been opposed to NICE, arrguing that it represents a 'fourth hurdle' that places a further barrier between patients and their treatments. However, since most interventions that have been assessed by NICE have been recommended for use, a strong argument can be made that the pharmaceutical industry has done very well out of this process, with their interventions reaching patients throughout the NHS quicker and more 'completely' than they otherwise might have done.
|Government||very supportive||strongly opposed|
|NHS||very supportive||strongly opposed|
|Pharmaceutical industry||very supportive||strongly opposed|
|Patients||very supportive||strongly opposed|
|Pharmaceutical industry||very strong||none|
NHS organizations have to implement positive recommendations from NICE. Negative recommendations from NICE are a little more tricky, but if past recommendations are anything to go by, there won't be too many of these. Since NICE was created, it has produced guidance on 195 pharmaceuticals, 56 procedures, 17 diagnostics, and 113 devices, and the Department of Health has itself stated that the 'majority of appraisals have suggested partial or full use of technologies'.
What might prove interesting with the increased focus on public health interventions in the twelfth work programme is whether adequate data exists on many of these types of interventions, with respect to either costs of effectiveness. Although some of these interventions (e.g. smoking cessation policies) have quite a firm evidence base, it will be interesting to see what types of evidence NICE relies on when constructing their guidance for these programmes generally.
The Healthcare Commission, another centrally-run institution in England and Wales, monitors the extent to which local NHS puchasers and providers comply with NICE guidance. As far as I know, there has generally been a quite favourable compliance with the (mostly positive) NICE recommendations, although negative recommendations tend to cause much controversy among the media, affected patients/patient groups, and (sometimes) Opposition parties.
The review programme can best be described as ongoing
The evaluations are outcome-based, but the compliance with guidance is process-based
I expect that NICE will make mostly positive recommendations, and the general practiitioners will once again wonder how they are going to fund all of the new interventions and drugs that they will be expected to provide, but will manage somehow. There may be one or two negative recommendations, and, if so, these are likely to stoke controversy. As noted above, it will be interesting to see what forms of evidence NICE uses for those interventions and programmes in public health, where a strong evidence base often tends to be lacking.
|Quality of Health Care Services||marginal||fundamental|
|Level of Equity||system less equitable||system more equitable|
|Cost Efficiency||very low||very high|