Examination of Witnesses (Questions 420
WEDNESDAY 30 JANUARY 2002
420. Do people bring in their own advisers and
(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
(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
(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.
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 activitiesaudit,
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. Capacitywe know all about that,
do we not? What is the make-up of NICE staff? How many have recent
(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.
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
(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.
(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."
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
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.
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.
439. There was a suggestionI do not know
this to be true which is why I am askingthat 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