Memorandum by the British Medical Association
1. The British Medical Association is a
professional association representing the interests of doctors
throughout the country. It is also an independent trade union,
an educational and scientific body, and a publishing house. Its
views are based on the practical experience of its members80
per cent of doctors practising in the UK.
2. The BMA was originally supportive of
the establishment of NICE, and we continue to believe that it
fulfils an essential function and helps to contribute to the prioritisation
of resources. Our comments below are intended as constructive
criticism and should be taken in the context of overall support
3. In general we are satisfied with the
clarity and credibility of guidance issued by NICE. However, it
has been criticised in the past for a lack of openness and clarity
in its assessment procedures.
In particular, the reversal of its decision on zanamivir (Relenza)
was widely seen at the time as influenced by pressure from the
4. Such perceptions inevitably call into
question the credibility of the guidance issued by NICE and ultimately
of the organisation itself. It is vital therefore that the assessment
procedures followed by NICE continue to be both rigorous and transparent,
that its performance is monitored to ensure that it is kept free
of external interference and that it does not come under political
pressure to develop covert rationing decisions.
5. We are concerned that the work programme
of NICE is largely set by Ministers and is therefore influenced
by the need for political solutions. NICE itself should determine
its priorities, drawing on public and professional concerns where
appropriate. It must become responsive to important therapeutic
advances to enable doctors to prescribe effective new treatments
without undue delay. In this way, it would often be able to address
issues before they became overly politicised.
6. Although the establishment of NICE was
intended to eradicate "postcode prescribing", its success
in doing so has been constrained by the ability of individual
health authorities and primary care trusts to determine whether
to implement its guidance locally. Many are guided in their decisions
by pressure on resources and the need to cut budgets. As a result,
the issuing of national guidance by NICE has had little effect
on regional variations in the availability of treatment.
7. The BMA welcomed the recent announcement
by Lord Hunt that, from January 2002, health authorities and PCTs
will be obliged to fund treatments recommended by NICE. This should
help to provide a single national focus. However, extra funding
must be made available for these treatments to ensure that other
areas of healthcare are not starved of resources as a result.
8. There is an inherent contradiction between
the concept of local ownership and that of a single national focus.
Until now, the latter has been subject to local decisions on whether
to implement NICE guidance. This area of local decision-making
will no longer be available and it is not clear how the goal of
local ownership will be achieved in the future. More explicit
guidance on the scope of local ownership would be useful.
9. We are particularly concerned that PCTs'
budget decisions will be driven largely by the recommendations
of NICE and the requirements of national service frameworks, leaving
very little scope to invest in locally-determined priorities or
resolve local problems with local solutions. We are already aware
of many cases in which overspending on prescribing budgets has
resulted in pressure on other areas of expenditure. Again, sufficient
resources to implement NICE guidance without detriment to other
areas of healthcare is the most important factor.
10. NICE guidance is generally well received
and supported. Our only concern in this area is that cost-effectiveness
can be very difficult to determine and that this factor is often
not included in NICE appraisals. Ideally this assessment would
incorporate, in addition to a measure of cost per quality adjusted
life year (QALY), subjective criteria such as ethical and value
judgements. For example the controversy over the use of beta-interferon
for multiple sclerosis sufferers has highlighted the importance
of consulting users.
11. The recently announced establishment
of a citizens council should do much to ensure that subjective
criteria are considered. We hope that NICE also continues to develop
rigorous methods of assessing cost-effectiveness in terms of cost
1 Kmietowicz Z. Reform of NICE needed to boost its
credibility. BMJ 2001 (323:1324). Back
Smith R. The failings of NICE. BMJ 2000 (321:1363-1364). Back