NICE is not perfect. It never has been. It has, though, been a good start at trying to examine evidence and come to a fair and equitable decision as to what healthcare interventions to publically fund. NICE has faults. It has become a bit too easy on lobbyists – especially health care charity lobbyists – and it has not often published the detail of funding decisions pitched to them by pharma (they say it’s commercially confidential, I don’t think that’s good enough.) But NICE has protected us from some things. The hysteria of Herceptin, for example (doctors offering a standing ovation to unfinished research showing a small benefit, when the Observer leader told us it was an ‘instant cure-all’. ) It has provided a second look at pharmaceutical companies offering false hope and large price tags. If anything, NICE hasn’t been strict enough, allowing people with self- interests to serve on committees and in potentially conflicting ways; but it was much better than the mess of local funding and inequality which preceeded it and which was grossly unfair.
Lansley has now decided to stop NICE’s power of rationing. This is an odd political decision to make. The NHS has to be rationed in some ways – infinite spending does not compute. Politically, passing this chalice to a transparent and independent group working on the basis of evidence is a good one. The politician can decide how low (or high) a cost effectiveness computation has to be before they will fund it. But Lansley thinks that NICE should continue to merely issue guidelines -and frankly, doctors are awash with guidelines – but lose their ability to decide on rationing. That decision will be left, apparently, to individual doctors. What is the evidence that doctors will do this wisely, fairly, based on evidence? None. Before NICE, rationing was erratic, and the concept of evidence was relegated to whatever drug rep had just darkened a doctors’ door. If you look through any prescribing data from doctors you will find all kinds of non evidence based, expensive or brand name prescibing being done when an alternative would have been cheaper and just as good. But crucially, better prescribing is not just as good for the patient, but better for other patients, because there is more left in the pot to spend on them. American healthcare is a good example of ‘doctors choice’ gone berserk – non evidence based interventions are expensively everywhere and does no one any good.
I note that spokespeople for the pharmaceutical industry have been out in force, gleeful with Lansley’s decision, and supporting the idea that ‘doctor knows best’, and whatever a doctor thinks a patient should have, they should get. This is a disaster. The problem is that if you want to find evidence for anything, no matter how unlikely, to work, and you look hard enough, you can probably find it. What you may not have the luxury of doing is then searching for the full amount of research on the area and adding them up together – and finding that your proposition doesn’t work at all. This unblinkered view is what NICE proposed; to ensure that public money was not being badly spent. But now we will have Lansley’s brave new NHS world, with individual GP consortia now left to try and commission services separately – each trying to do a bit of what NICE did before. When NICE said that something wasn’ t cost effective, it was a fair and transparent statement of what the NHS would and wouldn’t fund. Patients could accept that. Doctors worked to it. But now, there will be no such dignity. Doctors, with ‘the ability’ to prescribe what they want, will be placed in harsh places when desperate patients want things that are very unlikely to work – and the freedom to go elsewhere if- if – that doctor declines. For what individual doctor will feel that they have the authority of NICE ? Thank God I’m in Scotland.