Neutering NICE

The demotion of the National Institute for Health and Clinical Excellence (NICE) from NHS head-teacher to somewhere between a dinner lady and a classroom assistant caught the quango by surprise. An e mail sent by chief executive Sir Andrew Dillon to NICE committee members suggests he wasn’t in the loop: “I am sorry that speculation on the future of the appraisal programme has appeared without me being able to forewarn you. We were also taken by surprise.”1 But the neutering of NICE started with health secretary Andrew La-La Lansley’s pre-election pledge of a cancer drugs fund to pay for drugs that doctors and cancer patients wanted, but NICE didn’t think were cost effective for the NHS. If NICE’s judgements can so easily be bypassed by one politician, there is no point in making them mandatory for the rest of the NHS.

In 2006, as chair of the NICE conference, MD invited then shadow health secretary Lansley to say: ‘There is, and has to be, rationing in the NHS.’ (Eye 12.12.06 ). He duly obliged, and the NICE hierarchy relaxed, safe in the assumption that they had devised the fairest system for rationing the NHS had ever seen, and no health secretary of any party would be stupid enough to tear down their firewall between politicians and the press.

But Lansley has done just that. NICE will continue to produce reams of guidance, at least for now, but the NHS will no longer be obliged to follow it. Instead, decisions about what doctors can and can’t afford to prescribe will be made by, um, doctors – at least until the money runs out. From October 1, £50 million has been put aside in the cancer fund to take us through to March 2011, with £200 million a year available thereafter. But why just a cancer fund? Why not a fund for MS or rheumatoid arthritis? It makes no moral sense. And what happens when a single drug such as Avastin takes out the entire cancer fund and there’s no money left for Glivec? Or Mrs Black at number 32 gets her cancer drug, but Mrs White at 31 doesn’t because her cancer struck late in the financial year.

NICE is not perfect. Its measurements and benchmarks are limited and crude, but far better than anything else we’ve come up with. It had got a bit bloated and pleased with itself, and some staff found it a macho and unforgiving place to work. But at least it tried to make sense of the drugs’ budget and standing up to the might of the industry in a way not previously seen. NICE already recommends 75% cancer medications. Pausing for thought over the remaining 25% that offer a few months at a huge cost is not always a bad thing (unless you only have a few months to live)

Even big pharma isn’t celebrating. At least companies know the rules with NICE and roughly what they had to do to get approval. The thought of selling to 150 struggling GP consortia fills them with dread. Bring back the cheer leader reps, the branded pens and the educational curries. La La is married to a GP, and appears to have a touching faith in our abilities. As well as taking over from the doomed Strategic Health Authorities and Primary Care Trusts, GP consortia have to cut management costs by 45%, save £20 billion through something called QIPP, learn how to procure and commission £80 billion of services and get to grips with an incomprehensible new way of paying for drugs called Value Based Pricing. If you’re really lucky, we might even see some patients.

1 http://www.healthpolicyinsight.com/?q=node/836

Ra Ra Rationing

NHS Warwickshire – a bust primary care trust – is racing ahead with rationing ahead of the financial squeeze. Some cataract removal and hip replacements are among the restricted treatments. For the full list of doom, go to http://tiny.cc/3ywu6