Reforming NICE would empower the drive to address health inequalities

Pronouncing the health service to be “broken”, on 11 July the new health and social care secretary, Wes Streeting, commissioned Lord Darzi to undertake a review to “diagnose” key challenges and how they should be addressed. He emphasised that he wanted a “raw and honest” assessment that will deliver “the hard truths”. 

The report is expected to be published this week. It will be be the start of a long process to address the multiple challenges facing the NHS and social care. There will be a need to prioritise any changes, as proffered solutions by all the key players will be multitudinous. What should be the balance between prioritising acute care, primary care, and social care – all essential for an effective and sustainable health system? What is the balance between local autonomy and central standard setting, including the role of integrated care systems?

Of course, the NHS is familiar with making difficult prioritisation decisions, and central to its approach in this context has been the National Institute for Health and Care Excellence. 

NICE (then the National Institute for Clinical Excellence) was established on 1 April 1999 to give a strong lead on assessing clinical and cost-effectiveness, and developing guidance that would reach all parts of the service. Since then, it has expanded its brief to public health and social care. This year the Institute celebrates its 25 year anniversary.

To coincide with this, Routledge has published a new book, “NICE at 25, a quarter century of evidence, values, and innovation in health”. The book, edited by ourselves, draws together essays analysing the key issues which have informed NICE’s work, from the principles of health economics, to patient engagement, to the legal framework within which NICE operates.

The book identifies that central to the Institute’s success was the acceptance that treatment options within healthcare needed to be prioritised. Early on, the Institute announced a set of guiding principles for all its endeavours. These were to be based on the best available evidence; decision making was to be open and transparent and involve all stakeholders likely to be affected (including academics, health practitioners, managers, industry, patients and the public); and draft guidance would be subject to open consultation, be appealable and regularly updated.

In essence, this was the practical manifestation of an approach to health prioritisation coined “accountability for reasonableness” by Harvard population ethicist Norman Daniels. What separated NICE from nearly all other clinical guidance developers was that it was required explicitly to take into account the cost of interventions – it was to assess value for money. The core methodology adopted was cost-effectiveness analysis, advocated by Alan Williams, including the concept of the opportunity cost, reflecting the view that you can only spend one health pound once.

The book argues that a key reason for NICE’s longevity has been its willingness to listen to criticism of its methods and to make adjustments accordingly. However, the presence of so many stakeholders with often contradictory aims and objectives has required a careful juggling act. While this has been managed sensitively during much of its lifetime, there are now rumblings that some stakeholders, such as large actors in the healthcare industry, are dominating methodological developments. Contributors to the book suggest that an ongoing governmental policy to incentivise innovation means that the Institute’s original goals of fairness and addressing inequalities are not featuring as prominently as they should.

Lord Darzi is likely to consider innovation as a key part of his review. How the Institute is able to delineate its role in this respect will be critical. In Chapter 2 on NICE’s economic methods, a radical change to NICE’s approach to health technology appraisals is advocated. The authors suggest that what is needed is to concentrate on one specific task in a trio of complementary decisions:

1. An independent and evidence-based assessment of the additional costs and benefits of new technologies (conducted by NICE);
2. An independent (including from NICE) and evidence-based assessment of health opportunity costs; and
3. A more effective central pricing or reward mechanism which would draw upon these.

NICE would continue to issue guidance. But instead of being a highly redacted justification for the decision to approve or reject a new technology, this would instead set out the appraisal of evidence, supporting estimates of health effects and NHS costs. As well as informing the centrally conducted pricing negotiations, the guidance documents would seek primarily to inform local prescribers/commissioners when making choices about treatment options for particular patients, identifying limits to appropriate use.

This would enable the closer integration of NICE technology appraisal with clinical guidelines. As it originally did, NICE would focus on supporting standards of clinical care in respect of innovative technologies – rather than valuing innovation in itself – thus resonating with Darzi’s concern with “quality of care as the organising principle of the NHS”.

Another key area that needs exploration, in light of ever increasing financial pressures on the NHS and the consequent need to focus more on prevention, is the role of NICE in Public Health. The book charts NICE’s experiences in working in this sector and suggests that it merits higher profile and priority. Whether the Institute as currently constituted is currently fit for purpose in this regard is not clear. Certainly the loss of the Centre for Public Health Excellence means that new approaches will have to be developed and tested.

Our reflections upon the past quarter century of NICE’s existence lead us to conclude that the Darzi review needs to take a new look at NICE and to propose how it should evolve over the next 25 years. We eagerly await its recommendations.