Mr NICE

A five minute interview with Andrew Dillon, c hief executive of the National Institute for Health and Clinical Excellence

NICE was set up to address postcode prescribing and to provide consistency. Do you think it has succeeded?

NICE was established to provide the NHS with the tools to address postcode prescribing and we have succeeded in that. There can be no doubt that NICE guidance provides consistent national advice for the NHS and for the people who use it. I don’t think anyone would want to go back to the pre-NICE era where patients living just streets apart were being treated differently because of their address. All the research we do, which can be found on our website, shows that when NICE recommends a drug or treatment, uptake in the NHS increases.

Isn’t NICE rather toothless since there is no obligation for a PCT to purchase a drug which NICE considers to be safe and cost effective?

Since 2001 the Department of Health has placed a very clear legal obligation on the NHS to fund NICE technology appraisal recommendations within three months of it being issued. Additionally implementing NICE guidance is part of the Standard for Better Health criteria which forms the basis of the Healthcare Commission annual inspections. There is a good mix of carrot and stick approaches to encourage implementation of our guidance.

Why can’t the health technology appraisal process be more transparent and open to external scrutiny?

Our processes have just been through a rigorous assessment in a court of law where the judge ruled that we are open, transparent and fair. We regularly open our processes up to external scrutiny by internationally renowned organisations such as the World Health Organisation (WHO) to ensure that we are developing our guidance to the highest standards. We publish all the evidence we consider, plus details of the committees’ decision making process on our website and all our guidance is subject to public consultation. We’re also currently thinking about holding our committee meetings in public. In fact, I struggle to think of any other organisation that is more transparent than NICE. It’s a model for British public decision-making.

Why do the All Wales Medicines Strategy Group and the Scottish Medicines Consortium complete assessments much more quickly than NICE?

They do a different although related job. They would be the first to agree that their processes do not consider the evidence in the same way or to the same extent as NICE. It is the NICE process which the WHO regards as the international leader and which the rest of the world acknowledges as the gold standard for drug evaluation. Both the Welsh and the Scottish bodies initiate their evaluations on the application of the companies. NICE must wait for Ministerial referral. We take evidence from a wide range of sources, including professional bodies (such as the Royal Colleges), and patient organisations, we also commission an independent academic assessment of the evidence, whereas the Scottish and Welsh organisations consider submission from the drug manufacturer only. We also carry out public consultation, which neither of the other organisations do, meaning that people have the chance to tell us if they think we’ve got it wrong and make reasoned arguments about why our recommendations should change. These things all take time, but we think our guidance is better for it at the end of the process.

Do the three bodies talk to each other or collaborate? Of course. We have strong links with both these organisations, and in recognition of the robustness of our process, both bodies routinely replace most of their guidance with ours when it’s published.

Is it possible for a product to be approved by one body but not by another? Yes this has happened, but only very infrequently. In most cases where there is a difference between NICE and either the SMC or AWMSG this is ironed out when NICE issues its guidance. The only exception is when NICE issues guidance from its rapid appraisal programme; this doesn’t apply in Scotland (although it does in Wales).

If so, on what basis? Surely a product is either cost-effective and beneficial or not. The differences in our processes can mean that we reach different conclusions; because we take evidence from a wide range of sources and carry out a public consolation, our decisions are influenced by a wider evidence base. Our work requires judgements (scientific and social value judgements) to be made and when two or more bodies are asked to make such judgements it is inevitable, from time to time, that they will come to different conclusions. Whether this is a good or a bad thing is for others to say, but it is the case that in a devolved health system, such differences are bound to occur. 

When you consider the economic benefits of a drug do you take into account the high cost to the taxpayer of instutionalisation. For example, wouldn’t it be more cost effective to approve a drug which costs £2.50 a day if it meant the sufferer could be cared for in the community.

NICE takes into account the costs to the NHS and personal social services costs when making decisions. Our statute, as set out by the Secretary of State for Health, does not allow us to take into account wider societal costs such as unemployment. So in answer to your question, yes we do weigh the cost of treatment against savings in other parts of the NHS or social services. Unfortunately, even if a drug seems cheap, if it does not work very well it will never be a good use of taxpayers’ money. Every pound spent by the NHS on an ineffective treatment is a pound that can’t be spent on one that works.