Published: 19/06/2003, Volume II3, No. 5860 Page 30, 31
Since it was created three years ago, the National Institute for Clinical Excellence has become best known for the research and publication of specific, mainly technical, reports. But what has been the overall direction of this work and what kind of healthcare has NICE been about?
Of the 62 technology appraisal reports published between April 2000 and May 2003, in terms of subject the reports can be grouped as follows:
Cancer treatment (18 reports): only one of these is on screening.Most are on chemotherapy for second-line treatment of late-stage cancer.
Heart disease (six reports): these relate to secondary care and treatment of patients with very serious heart conditions.
Surgery (eight reports): these mainly relate to orthopaedic implants and to laparascopic surgery.
Primary care (12 reports): these relate to diabetes, asthma, gastro-oesophageal reflux disease, the treatment of flu and arthritis.
Lifestyle drugs (five reports): two reports are on medications for weight reduction, one on treatment for attention deficit; one on hearing aids and one on smoking reduction.
Central nervous system and mental illness (six reports): these cover Alzheimer's disease, atypical anti-psychotics and cognitive behaviour therapy, multiple sclerosis and motor neurone disease.
Long-term medical conditions (seven reports): most of these are about aspects of treatment for chronic medical conditions - rheumatoid arthritis, Crohn's disease and renal failure.
Cancer treatment: these reports are mainly short and give positive recommendations. They present little evidence in terms of quality-adjusted life years (QALYs) and the general doctrine is that treatment costing£6,000-£10,000 a patient, which can lead to two or three months' survival benefit, is now to be funded.
The reports have been followed by a rapid increase in funding for chemotherapy, with Department of Health estimates of extra spending at£33m in the last year. There is little emphasis on long-term care programmes (most of the reports relate to later stages of the disease) and few recommendations for further research. Reports address the imperative of reducing postcode rationing in access to these drugs. The number of reports and the speed at which they have been produced surely reflect the political and patient sensitivity of this area.
Heart disease: these reports are complex discussions of stents, implants and so on. Generally, NICE takes a positive view of treatments in this field. Some cost effects are likely to be reduced because there is already a high level of use and there is little discussion of the evidence on effectiveness, which is taken as given. Cost per QALY is generally presented by NICE as favourable.
Surgery: the reports in this area have been more negative. NICE ruled against prophylactic removal of wisdom teeth, cartilage transplants and use of laparoscopic surgery for colorectal cancer and (except in a few cases) laparoscopic methods for hernia repair. Its conclusions on hip replacement prostheses and wound debriding left people free to make their own decisions. NICE recommended surgery for weight reductions only under strict conditions through specialised units.
Primary care: NICE was very positive for active treatment of type-2 diabetes. For proton pump inhibitors, cox 2 inhibitors, and the use of Relenza for influenza, NICE recommended a stepped approach targeting higher risk or higher benefit individuals without any general approval for wide use of the therapies.However, in practice the reports may be interpreted by primary care trusts and their professional executive committees as requiring a general review of all patients so as to identify those target groups. So though NICE was pointing towards selection, this may not happen in practice. For these treatments NICE used evidence from a number of large-scale trials, allowing greater segmentation of the patient populations pointing towards different, more selective, strategies for use.
Lifestyle drugs: these reports overlap with the primary care section and the same approach of targeting was used.Here there was more emphasis on prior or complementary use of non-drug treatments and lifestyle changes. The reports seemed likely to limit use rather than increase it.
CNS/mental illness: these reports were longer and dealt with larger patient groups (apart from motor neurone disease). Distinctive features included an emphasis on reserving treatment decisions to secondary care and setting long-term care programmes and care pathways. The Alzheimer's report was notable in the size of the research agenda recommended. Even the negative MS report was followed by an agreement to develop a care pathway with monitored results. The CNS reports were unusual, dealing more with long-term treatment processes rather than with a single episode use of therapy or equipment. They were also more likely to require prospective measures of benefit.
Long-term medical conditions: NICE was positive about additional treatment for long-term medical conditions - treatment of arthritis, Crohn's disease, human growth hormone and home dialysis.
Reports on arthritis and Crohn's disease used economic modelling to produce estimated cost per QALY, in the£25,000-£35,000 range.
The future NICE started life facing issues about its role and only now has it got scope to develop its identity.
Many of its past reports were important to specific groups but were less likely to have much impact on total NHS performance.The first 62 reports cover areas of healthcare which account for less than 30 per cent of NHS spend. It has said little to help dayto-day challenges in areas like wound care or elective surgery.
NICE certainly has a continuing role as a court of appeal and source of evaluation for new therapies.
However, it has also to find ways of promoting clinical excellence in more general terms. It has an efficiency as well as an equity role.A key challenge is identifying technologies to benefit more patients - perhaps in the IT/communications area.
Much of the NICE agenda has been about 'hardware'. It focuses on new programmes rather than on ways of getting more value out of the great resources already possessed by the NHS.
Until now, NICE has been about the start of the innovation curve.The Modernisation Agency is working at improving services through changing methods - but NICE seems curiously detached from such activities.
It should also be monitoring the actual results of NICE reports, a role which is not being carried out fully at present.There are already serious new problems of postcode rationing with the new Alzheimer's drugs and in other areas.
A more strategic approach would give greater emphasis to technologies which would assist prevention and early intervention. In many areas of healthcare, the greatest gains are likely to be in preventing disease.NICE has looked closely at diabetes but there are other areas where more focus is needed.
NICE is now more active in primary care. But it needs to focus more on innovations which will raise NHS performance in delivering effective care for larger numbers of patients. For example, early, fairly negative, advice on new hearing aids has been withdrawn without any replacement - surely an inadequate response.
NICE has also been affected by clinical specialisation, which drives it to see the healthcare process in clinical fragments. It has become a kind of oracle on higher therapies rather than identifying strong levers for better resource use.
Its reports do not seem to be based on any overall strategy for promoting clinical excellence and may indeed have the effect of tilting the health service towards more specialised types of secondary care.This approach may also have helped create new problems for budgeting and postcode rationing.
Now NICE has a chance to reconsider its longterm role and to give clearer signals to the NHS about such issues as the role of prevention, care integration and paths to reducing long-term costs through timely treatment. l Further information l For a detailed list of NICE reports: www. nice. org. uk Nick Bosanquet is professor of health policy at Imperial College, London.
Key points lNICE has published 62 technology appraisal reports in three years.
lMany reports refer to complex, specialist topics and affect only small numbers of patients.Some opportunities to give clear guidelines have been missed.
lThere is scope for reports designed to maximise existing NHS resources and to assess the role of prevention, care integration and other ways to cut long-term costs.
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