Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 420 - 439)



  420. Do people bring in their own advisers and lawyers?
  (Professor Sir Michael Rawlins) Oh yes; they come with lawyers, other doctors, and also some of the relevant members of the Institute staff are present.

  421. It is not a public occasion though, is it?
  (Professor Sir Michael Rawlins) No, but we are about to consult on a document where we would make it public unless there is confidential data, which is actually very unusual. We are proposing in future to hold appeals in public.

  422. The Food Standards Agency, which is another body I quite like, seem to get a very much better press than you do. I can imagine that there are lots of pressures and so on but they are very open. Virtually everything they do is on the Internet as they do it.
  (Professor Sir Michael Rawlins) Most of our stuff is on the Internet as we do it and we have 15,000 hits a day, rising to 30,000 or 40,000 when we publish a new piece of guidance.

  423. Their meetings are public also.
  (Professor Sir Michael Rawlins) All our Board meetings are held in public, yes.

  424. I am talking about the appeals. The Food Standards Agency, all their meetings are in public. You are moving in the same direction?
  (Professor Sir Michael Rawlins) Yes.

  425. You have just said that appeals have to be approved by the Chair of NICE before they go to the Appeals Committee.
  (Professor Sir Michael Rawlins) Yes.

  426. Do you think it is appropriate that you are both the Chair of NICE and the Chair of the Appeals Committee?
  (Professor Sir Michael Rawlins) I think so, yes. As Chairman of the Institute I and the non-executive directors are expected to have an oversight over the activities of the Institute in all terms including its financial affairs. We are charged with responsibility for the Audit Committee, the Risk Management Committee and things like that, and it seems to me that there is no reason why we should not be equally capable of having oversight over the clinical and technical processes that are going on as well, not to pretend that we are health economists or that we are necessarily expert in individual decisions, but to make sure that the decisions have been made properly, reasonably and within the legal boundaries of the Institute's working. We are quite capable of doing that. We have two independent members who are also present and they add a valuable component and I am sure if ever the occasion arose that they would wish to dissociate themselves from the other three members' advice. It has never happened though.

Siobhain McDonagh

  427. I want to ask a few questions about the resources that are available to NICE. Has NICE the resources to match the current expectations upon it?
  (Mr Dillon) When we started we had just about £10 million and pretty much all of that money was being spent already by the NHS on different aspects of our work, £2.5 million or more on the four national confidential inquiries; around £4 million was being invested in the national professional organisations, including the Royal Colleges, for various activities—audit, some production of government guidelines and some other work. There was some additional money put into the budget to enable us to do the new work of technology appraisals. As I mentioned earlier, we used money supplied by the NHS R&D programme to commission the independent reviews. The Nice budget has risen to £13 million in this financial year. The Department of Health and the National Assembly are adding a further £2 million in total to the budget next year. Our allocation has been rising quite rapidly therefore and we have been able to deploy that money very effectively. It is the case that in order to deliver on the expectations that the NHS has of us our budget has to continue to rise in that way because, as we have heard, demand for us to deal with the major priorities in terms of programmes on new technologies and clinical practice guidelines as quickly as possible is increasing. To do that we need to have the resources. So far it looks as if we have convinced the Department and the Assembly in Wales that we are doing a good enough job to be given those additional resources and I very much hope that continues. There are a number of limiting steps though beyond the actual amount of money. For example, in order to produce a clinical guideline, which takes about two years, it needs very considerable resources to be available. What we have done is to work with the Royal Colleges and other professional organisations to develop six collaborating centres and they are the engines of our guidelines production process. We have pretty much brought up the guidelines' authoring capacity in that form in the UK. In order for us to do more it is not just a question of money; we also need to get hold of the people to do it.

  428. Capacity—we know all about that, do we not? What is the make-up of NICE staff? How many have recent clinical experience?
  (Mr Dillon) We have about 40 staff who are directly employed by the Institute but the Institute is more than just the people who work in the main office. When we established NICE we established it on the basis that we keep the overheads as small as possible. We are very conscious that what we have spent is top sliced in fact from the allocations that go out to health authorities and PCTs. What we wanted to do was to work on the basis that we would source the clinical advice that we need from those people who are in clinical practice. That is why David Barnett, who is Chairman of the Appraisal Committee, works very closely with those in the advisory committees of the development groups. All the development groups consist of clinicians (where they have clinicians) who are in active clinical practice. When the Appraisal Committee needs to consider technology it takes evidence from clinical experts, people who are treating patients and may be using the technology right now. The people who are employed at NICE have various specific skills that enable us to commission pieces of work to prepare documents. Their job is not to interpret the evidence. Their job is to provide the arrangements to enable our independent advisory groups, like the Appraisal Committee, to do its work.

  429. The Phillips report into the BSE inquiry recommended that the Government retain sufficient expertise in-house "to ensure that departments are able to identify where there is need for advice, frame appropriate questions, understand and critically review the advice given and act upon it in a sensible and proportionate manner". Is this something NICE would be in favour of?
  (Professor Sir Michael Rawlins) Yes, very much so. I read that report some time ago but with very considerable care when NICE was being set up because we also have similar obligations. I would just say one thing. You were told last week that many of our staff had worked in the Department of Health. Actually only one member of the staff of the Institute is a former employee of the Department of Health.

  430. A further claim last week was that the people doing research for you, you have now decided, were people not appropriately qualified to be doing the work, or that there were not enough of them appropriately qualified.
  (Mr Dillon) It is absolutely not the case that they do not have the qualifications or the experience to do the job. It is the case though, just as there are capacity problems in the centres that we commission to produce clinical guidelines which limit us, that staff come and go and those academic departments face difficulties from time to time in ensuring that they have got sufficient resources. The workload that they take is consistent with the people that they have in place, both the number of people and their qualifications. It is absolutely not the case that they lack the skills to do the job.

Andy Burnham

  431. Can I touch on a few questions relating to your public image and your media strategy? Speaking as somebody with some experience and knowledge of these matters, I have to say I have noticed that you run a very quick rebuttal service when there is adverse press comment about NICE. I note that after Gordon McVie spoke to the Science and Technology Committee you were very quick to respond to those concerns. We could recommend that we would like to learn some lessons from it. Could you give us some flavour of what your strategy is to the media presentation and response? I hasten to add that you are doing a very sensitive and difficult subject; I understand that, and I do accept that you need clear comment out quickly when there is criticism of you.
  (Professor Sir Michael Rawlins) Yes, and one of our problems in a sense, which will always remain with us, is that we will only please some of the people some of the time. We will never please everybody all the time. I guess you have the same sorts of difficulties in Parliament too.


  432. Absolutely.
  (Professor Sir Michael Rawlins) We recognise that. We are conscious that we are earning the respect of health professions generally and of the community at large. Every year I go round and talk to the senior officers of the Royal Medical, Nursing and Midwifery Colleges and they are very supportive. They say, "Sorry that you are getting criticism from time to time. It will happen. You know that, do you not, but we are behind you."

Andy Burnham

  433. Is it leading you to be over-defensive though and too quick to respond? I can understand if it is. I know it is not easy.
  (Professor Sir Michael Rawlins) Sometimes we get things wrong and when we get things wrong I hope we always put our hands up and say, "Yes, we got it wrong", because there is no point in confabulating. When we have got things wrong we have said so. One of the great difficulties that we have, and it is a very tough problem to put across, is that we are having to balance the interests of individuals or groups of individuals against patients as a whole who come for treatment to the Health Service. There is a finite pot of money that we have available. We believe our job is to try and get the greatest benefits for all patients from the funds that you vote for health care in Parliament. Getting that across is not easy. Certainly we do have a very active Director of Communications who is sitting right behind me. I do not know whether Andrew wants to comment further on that.
  (Mr Dillon) Just to go back to the first part of your question when you were asking about the strategies that we have in place. What we aim to do is three things. The main purpose of the communications function that we have and the capacity that we have got is obviously to make sure that the guidance that we produce gets to the people who need to read it. That is very much the community of clinicians in the NHS that we work for and those who manage the delivery of services. Equally, it is absolutely the public as a whole and particularly those groups of patients that have a specific interest in the guidance that we are producing. That is the main thrust of the communications effort. Also we need to communicate our purpose, so part of our effort is to make sure that the public as a whole and the NHS know why we are here and what we do. Thirdly, it is to make sure that we put on the web site, but we use other media as well, adequate information about our current work programme. We were discussing earlier the problems of people not being certain about Herceptin. We are very careful to make sure that where there is a change in any published time line for appraisal it is made available and put on the web site. Communication is clearly absolutely the core of what we do because it is important to get messages out to the public with no spin attached to them.
  (Professor Sir Michael Rawlins) There is one other aspect to it and that is that we are producing versions of our guidance that are, we hope, intelligible to the public and we have gone to some considerable trouble to do that. We do that for two reasons. One is that we believe patients have a right to know what is happening and why it is happening. Secondly, and I have said this in many public audiences so it is not a great revelation, we do know that the implementation amongst health professionals of such guidance is substantially increased if patients have access to it. They basically wander into doctors' consulting rooms or surgeries holding the guidance in their hand and saying, "Why am I not being treated in this way?" this informs the consultation. We do it for both reasons; both are very important to us.

  434. Do you accept that over-sensitivity to press criticism may give off the other message as well, that there is something wrong?
  (Mr Dillon) There is always the danger of that and it is a judgement. Where either somebody says something about the Institution that is just plain wrong, or where they are expressing a very strong view that seems to us to completely misrepresent what we are doing, it is important that we put on the record what the truth is.

  435. Do you think you get a fair hearing from the press and the media?
  (Mr Dillon) In most cases when we publish guidance the guidance itself is reported faithfully and that is the most important thing. There will always be opinion articles published on the Institute. Sometimes they are written in a way that we like, sometimes they are written in a way that we do not like, but that is the nature of being in the public eye and I guess it is the nature of the media.

  436. But the nature of your role, as you have said yourself, is that it is not going to be a popular job half the time, is it? I guess the communication strategy should bear that in mind.
  (Mr Dillon) Actually, this is the best job I have ever had in the NHS.

Siobhain McDonagh

  437. That was the question I was just about to ask you.
  (Professor Barnett) Me too.
  (Professor Sir Michael Rawlins) Me too.


  438. We have had a lot of submissions giving you fulsome praise. Are you trying to get out your own message that people are sympathetic? Is that something you are actively trying to do?
  (Mr Dillon) As I was mentioning earlier, the fact is that we have established ourselves on the basis that we were not going to create some kind of technology factory in the centre of London, shut the doors and lob guidance into the NHS unannounced, that we were going to work on the basis that we exposed the way we do things and that the people who actually write the documentation that we produce are people in clinical practice. They are the very people who are going to take the guidance and use it. I hope that the people who have written to you in support of us are people who are in clinical practice and people who know something about the Institute and how we go about our work.

Andy Burnham

  439. There was a suggestion—I do not know this to be true which is why I am asking—that you were co-ordinating these submissions to the Committee.
  (Mr Dillon) Certainly not. We made sure that everybody involved in NICE work was aware that the inquiry was taking place and that they had an opportunity to submit to you. That is what in effect you invited yourself through the press releases that you made.

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