Memorandum by Newcastle and North Tyneside
Health Authority (NC 112)
INTRODUCTION
1. This evidence was prepared by Dr David
Walker, Acting Director of Public Health, on behalf of Newcastle
and North Tyneside Health Authority. The evidence was prepared
after consultation with clinicians and managers working in areas
directly affected by the work of the National Institute for Clinical
Excellence.
GENERAL COMMENTS
2. The work of the National Institute for
Clinical Excellence has been of general benefit to Health Authorities
in their planning and commissioning roles. The principal benefits
have been provision of clear guidelines, resolution of post-code
prescribing issues and provision of comprehensive analysis of
evidence, which is often impossible at local level. The appointment
of distinguished and well-qualified senior officers did much to
establish the credibility and authority of the organisation. Despite
the problems identified below, the organisation is regarded as
a valuable resource for Health Authorities.
PROGRESS TOWARDS
KEY GOALS
Providing clear and credible guidance
3. Guidance provided by NICE has generally
been clear and credible. The website and hardcopy publications
are well produced and distributed.
4. In some cases there has been a lack of
clarity in indicating how recommendations are supported by evidence.
This is particularly the case when evidence has included unpublished
data. An example of this was the appraisal of Zanamavir (Relenza).
The evidence published with the appraisal did not appear to support
the recommendations of the Institute. Rather than resolving the
issue, this led to an intense debate in the medical press and
the questioning of the credibility of the organisation.
Ending Confusion by providing a single national
focus
5. In the areas addressed by NICE, the recommendations
of the Institute are generally accepted as definitive and provide
a national point of reference for decision making. This has reduced
confusion.
6. NICE inherited a challenging backlog
of work in addition to emerging problems. There are many outstanding
issues that NICE has yet to address and may not have the capacity
to address in the future. Priority setting is a key issue for
the future.
Providing guidance that is locally owned and acted
on in the right way
7. There is an inevitable tension between
national guidance and local priorities. NICE guidance is based
on broad consultation with stakeholders but local Health Authorities,
who are required to ensure the implementation of the guidance,
are unlikely to be consulted and have no right of appeal against
draft appraisals. There is a perception that NICE guidance is
imposed rather than locally owned.
8. The allocation of funding for the implementation
of NICE guidance has not been universally equitable. The uplift
to allocations in some parts of England last year, which included
a proportion for implementation of NICE guidance, did not take
account of the differential use of drugs approved by NICE in different
NHS Trusts.
Actively promoting interventions with good evidence
of clinical and cost-effectiveness so that patients have faster
access to treatments known to work
9. NICE guidance is powerful in promoting
interventions with good evidence of clinical and cost-effectiveness
but may not provide faster access to those treatments. In a few
cases the duration of the process has been unacceptably long,
for example the use of beta interferon for the treatment of multiple
sclerosis. This may result in a polarisation of views which may
not be resolved by the publication of the guidance.
10. The long duration of NICE appraisals
often results in an interim decision being taken by Health Authorities
and PCTs. Indeed this is often encouraged by the Department of
Health, for example in the appraisal of Glivec. This presents
difficulties when the interim decision conflicts with the final
NICE recommendation.
RECOMMENDATIONS
11. The capacity of NICE for technology
appraisals should be increased to reduce the delay between the
development of new technologies and the production of guidance
concerning their use.
12. A fast tracking route for key appraisals
should be established.
13. Health Authorities and PCTs should be
consulted as part of the appraisal process.
14. A feedback loop should be established
to inform NICE about progress in the implementation of guidance.
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