The wider prioritisation debate
130. The final issue that has arisen from our inquiry is the role
of NICE in relation to the wider debate on prioritisation in the
NHS as a whole. Many of our witnesses felt very strongly that
the new mandatory implementation of NICE guidance meant that NICE's
work programme now feeds into this prioritisation process in a
way not intended when it was originally set up. We have already
heard that considerable confusion exists over the separation of
the affordability and cost-effectiveness functions, and we have
recommended that the Government should attempt to clarify this.
However, even with affordability and agenda-setting decisions
placed firmly with government, our evidence suggests that there
is still a need for further debate and clarification. Professor
Walley described the issues in useful theoretical terms:
"Does NICE advice carry with it added resources to the NHS,
or as seems to be the case, redistribution of existing resources?
If this latter is the case, then all possible alternative uses
of the resources need to be considered and a review confined to
a single therapeutic area or technology is inadequate. A broader
approach is necessary, to cover a wide range of, or even all,
NHS activities."[183]
131. Croydon Health Authority offered a more practical perspective:
"Health authorities can only prioritise fairly if all competing
demands are considered at once. Because of the way in which it
has been set up, NICE does not do this, as it considers new treatments
at the margin of healthcare. In contributing to the prioritisation
debate in the NHS as a whole, it is therefore flawed. Until NICE
has evaluated things like the benefit of funding new nurses for
our local A&E department at the Mayday Hospital, then its
recommendations to fund certain treatments, which are by default
at the expense of this sort of development, cannot be rational
for local health economies."[184]
132. For NICE to conduct a full appraisal of the costs and benefits
of every possible service improvement in the NHS would clearly
be an unworkable aim within its present constitution and funding.
However, in establishing NICE and making its guidance mandatory,
the Government has provided a centralised valuation system for
one area of service provision, namely new and/or controversial
drug treatments and health interventions, without balancing this
against guidelines for any other elements of service provision.
This was illustrated very clearly by Mr Newdick, an academic in
the field of health law, who argued that "NICE's recommendation
of a treatment for reducing the symptoms of influenza by
one day commands the same access to resources as recommended cancer
treatments". Concluding his written evidence, Professor Walley
argued that "there is a need for a rapidly responsive source
of guidance for the NHS, but also for a body to take a broader
view of NHS priorities: this seems to be beyond NICE at the moment".[185]
133. As Lord Hunt suggested, weighing competing priorities is
inevitable for those who manage NHS budgets.[186]
However, NICE raises difficult issues by introducing a systematic
process for prioritisation in one area without extending the principles
and expertise informing this more widely. In his written evidence,
Mr Newdick suggested that primary care trusts need to be given
a framework within which to consider new drugs and treatments
which are not subject to NICE guidance, a point he developed in
oral evidence, and argued for the introduction of "a system
for gauging affordability ... according to a systematic series
of values and a framework of ethics, which would be vague and
imprecise, but would give us some idea about a limit on the demands
that can reasonably be made on a cash-limited system".[187]
134. Prioritisation of healthcare spending is an issue of overwhelming
importance, and during the course of this inquiry it has become
clear to us that a more open debate on healthcare prioritisation
needs to take place. Our inquiry has persuaded us that, with so
many competing interests vying for attention and funding in an
area where resources are finite, it is not sufficient to have
implicit healthcare prioritisation. We feel that NICE has been
laid open to unfair criticism in respect of the 'rationing' debate,
as a consequence of the lack of clarity in policy here.
135. Clearly, it would be beyond the scope of the present inquiry
for us to make specific recommendations in this area. We do,
however, wish to record our view that the Government must work
to achieve a comprehensive framework for healthcare prioritisation,
underpinned by an explicit set of ethical and rational values
to allow the relative costs and benefits of different areas of
NHS spending to be comparatively assessed in an informed way.
Such a framework would need to secure the input of the wider population
as well as NHS patients and staff, policy makers and academics.
Although we are not seeking a detailed response on this point,
we would welcome an acknowledgement on the part of the Government
that this is a key issue, and we would not be convinced if the
Government were to argue that prioritisation were already subject
to such a framework.
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