Select Committee on Health Appendices to the Minutes of Evidence


Memorandum by Dr Tim Kendall and Mr Stephen Pilling, National Collaborating Centre for Mental Health (NC 60)

  We are writing to you with regard to the current position and status of the National Institute of Clinical Excellence (NICE) to ensure that you are aware of our views as joint Directors of the National Collaborating Centre for Mental Health (NCCMH), recently established by NICE, and which is responsible for generating national clinical practice guidelines across the field of mental health. Each of us also work at all levels (local, regional and national) of the National Health Service (NHS), in both clinical and in management roles. One of us currently leads the clinical effectiveness unit of the British Psychological Society; the other is deputy director for the equivalent unit at the Royal College of Psychiatrists.

  1.  NICE undertakes a number of activities as a national body whose primary aim is to set national standards of health care so as to continually improve the quality of health care within the NHS. This is achieved through the development of national guidance and clinical practice guidelines, through national audit and National Confidential Enquiries. To achieve these ends, NICE have developed very good connections with the wide range of professional bodies involved in the NHS, including our own, with industry, and with service user and carer organisations. They have played a crucial role in the National Health Service in giving service users and carers a central role in our health serviceby giving them a key role in influencing standards in clinical practice and in placing evidence of clinical cost effectiveness at the top of the health professionals agenda. This has been a very substantial achievement, one we believe to be essential for the continued modernisation of the NHS.

  2.  NICE is clearly in an excellent position to achieve its aims, as set out in A First Class Service (clear and credible guidance, from a single national focus, actively promoting clinical and cost effective interventions that are locally owned and correctly used, resulting in patients getting more effective treatments more quickly). However, these aims amount to nothing less than a revolution within the health service, and will take rather longer to achieve than the two-and-a-half years that NICE have existed to date. Moreover, it is our view that NICE will achieve its aims more fully, and more quickly if: 1) it has, and is seen to have, greater independence and autonomy from the Department of Health, and 2) that the structure and function of NICE and the Commission for Health Improvement (CHI) within the "New NHS", as set out in A First Class Service, are strengthened rather than eroded. We have recently become concerned that these developments may be threatened by the current position of NICE, and some proposed changes identified in the Kennedy Report.

  3.  NICE is at present a Special Health Authority whose work programme is subject to the agreement of the Department of Health, and much of its internal arrangements are subject to government approval. Although these arrangements may have advantages, an important consequence is that NICE is perceived, whatever the reality, as being a means for the Department of Health to force changes upon the professions for "political reasons" rather than from a desire to improve the quality of health care.

  4.   We want to strongly recommend that NICE remains at the heart of the NHS (as a Special Health Authority), and is given greater independence from the Department of Health, putting NICE and its collaborating centres in a much stronger position to positively influence both the professions and the services they provide. This would necessarily involve NICE setting its own work programme following wide consultation with Government, the professions, service users and carers, but not directly under the central control of the Department of Health. With this greater distance from the Department of Health, NICE would, we believe, be more able to be the NHS "engine" for quality improvements that is so clearly needed. We also believe that this would further strengthen its relationships with the professions, service users and managers, and thereby increase its influence over the quality of clinical services in the NHS.

  5.  Our second concern relates to the different roles and activities of NICE and CHI, and the suggestion that NICE relinquish its role in National Audit and in National Confidential Enquiries and that CHI should take over these functions. The generation of guidance and national guidelines, the development of audit tools and national audits, and the convening of National Confidential Enquiries are all complimentary ways of improving the quality of NHS work and service delivery. Each of these activities should form part of an overall strategy and implementation plan to help the professions improve care and reduce variations in the delivery and quality of care. In addition, national multi-centre audits are necessarily linked to the generation of guidance: through national audit, NICE and its collaborating centres will be able to accurately identify shortcomings in the development and implementation of guidelines. If any of these activities were transferred to CHI it would be far more difficult to identify and remedy any problems, or to modify NICE's work programme or methods.

  6.  CHI is an external inspectorate, with all the necessary powers to call to account trusts, services and individuals within the NHS. In this role it must be able to name, and sometimes to blame, those who seriously fail to provide a modern and decent health service, or those who misuse or damage the NHS. In this role CHI is ill suited to undertake either national audit or National Confidential Enquiries. These activities depend upon a great deal of cooperation with NHS trusts and professionals, undertaken in an atmosphere of openness and honesty: they must be conducted in the context of a blame-free culture. They cannot be a part of, or seen to be a part of, external inspection. If CHI were to take over any of these functions, there is a serious risk that the results from both the confidential enquiries and national audits would be flawed providing an unreliable basis for initiating changes within the NHS.

  7.  We therefore want to strongly recommend that NICE keep all its current functions, including the generation of national guidance and national guidelines, the responsibility for National Confidential Enquiries, and the identification and development of national audits.

  8.  We are very supportive of the work of this Government, the work of NICE and of CHI, so long as their respective roles remain separate and clearly defined. The NHS is, for the first time in more than two decades, beginning to make genuine and sustainable improvements in the quality of health care and in the effective delivery of services. These changes cannot come overnight, and will always meet with resistance from many sources. We are coming to the end of the beginning of the New NHS: the success of the next phase of modernisation, we believe, will require both a NICE that has the power and independence to be able to drive up standards from within the NHS, and a CHI able to judge from without.

  We hope that these suggestions, and the concerns upon which they are based, will prove to be a useful contribution, and helpful in ensuring that the New NHS becomes a working reality.

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Prepared 8 July 2002