APPENDIX 12
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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