It not a NICE job but somebody has to do it
By Dr Paul Charlson
25/06/2007

A lady consulted me with a nasty rash. I could have prescribed a variety of treatments. My choice included an established cheap effective treatment with potential minor side effects. A modern medication with a lower side effect risk costing three times as much or a new treatment with a much lower side effect risk costing twelve times as much.
 
In this instance I chose the cheap tried and tested medication because of the small risk of minor side effects and my familiarity with its characteristics . A significant number of colleagues would have chosen the second option and a few the third and some something entirely different. Doctors often face such dilemmas. They are faced with a variety of treatments of variable safety, efficacy and cost. Because the NHS does not have limitless funds they are torn between needs of the patient sitting next to them and those of wider population. Like everyone else on a budget they seek value for money.
 
Finding value for money is never easy. Until recently Doctors lacked any authoritative guidance about which treatments worked and how cost effective they were. With so many new treatments emerging clinicians were unsure about which to choose. This lead to variations around the country the "post code lottery".
 
In 1999 NICE the National Institute of Clinical Excellence was established as an NHS agency. It was charged to develop recommendations and guidance on the effectiveness of treatments and medical procedures. In other words to try to standardise treatment across the country.
 
From the outset NICE's work was controversial. It recommended against prescribing Relenza a flu medication. Criticism from the pharmaceutical industry caused NICE to partially reverse it's recommendation in relation to "at risk" persons. Then the highly regarded and independent Drug and Therapeutics Bulletin gave contrary advice to NICE claiming its appraisal methods were flawed. Further controversy occurred when NICE shifted its position due to public pressure over the use of the extremely expensive beta Interferon in multiple sclerosis. NICE lost some credibility.
 
As recently as 2002 some NHS bodies did not feel obliged to follow NICE recommendations and the postcode lottery remained. In that year a House of Commons select committee reported that NICE lacked transparency and was not fully accepted by clinicians. It was urged to focus on winning the trust of NHS bodies and the public.
 
Since 2002 NICE has gained credibility but problems persist.
 
Its relationship with both the Government and the pharmaceutical industry threaten its credibility.
 
Many people believe that NICE should be independent of the Department of Health if it is to take on the role of providing the NHS with best practice guidance. Affordability should be a political decision taken by ministers who are publicly accountable.
 
NICE's relationship with the pharmaceutical industry is also a difficult one. Once a drug has been recommended by NICE its usage will increase. The pharmaceutical industry clearly has a vested interest in ensuring it's products are included in the recommendations. Consequently lobbying by companies and friendly specialists have lead to accusations of  bias. On the other hand NICE also has a remit to encourage new technologies and must not be "Luddite" in it's approach to approving them.
 
In order to ensure transparency and fairness in approving new technologies, NICE must carry out thorough appraisals which takes time, leading to "NICE blight". The NHS will not provide a new treatment until it is approved by NICE, the more thorough the appraisal the longer the "blight". Some cutting edge cancer treatments have been blighted in this way.
 
 
The NHS has a limited budget and some treatments despite being beneficial are too costly to be recommended by NICE. One of the criticisms of the organisation is that it has been unable to say no to costly and relatively cost- ineffective treatments.
 
In 2005  it appeared that NICE was beginning to flex its muscles. It decided that a number of expensive drugs used to treat Alzheimer's disease were not cost effective and should not be recommended for NHS use. However, following pressure from various patient groups and drug companies it has decided to consult further with the pharmaceutical industry to see if particular patient types might still benefit from the medication. The decision was deferred.
 
This situation encapsulates the dilemma facing doctors in the consulting room. It is terrible to have a relative with Alzheimer's disease. If there is a slim chance that a drug could improve the situation any relative is going to want it to be prescribed. Doctors are the patient's advocate and are trained to treat the patient, it is very hard for them to say "No". They are aware that if they prescribe an expensive possibly ineffective medication someone somewhere is going to miss out on an equally vital treatment. NICE needs to remove this type of the decision from clinicians.
 
The NHS is in a financial mess, partially because there have been no clear boundaries about what can be provided by it. Boundaries need to be set. Clinicians need authoritative evidence in order to make the right decisions. In order for NICE to provide such evidence it must be credible. Credible decisions acceptable to all parties require consultation. Consultation takes time and NICE has been criticised for deliberating too long. Yet if it makes a decision too quickly without consulting everyone it comes under fire for that. Similarly politicians are putting huge pressure on cost growth making rationing inevitable. Advancing technology is also inevitable and must not be overly rationed. NICE has a difficult job but someone has to do it.