Select Committee on Health Appendices to the Minutes of Evidence


Memorandum by the Chief Executive Hammersmith Hospitals NHS Trust (NC 106)

  I am delighted to have the opportunity to provide some comments from our perspective in relation to functioning of the National Institute of Clinical Excellence (NICE).

1.  Is NICE providing clear and credible guidance?

  NICE is to be congratulated on achieving a high quality standard format for their guidance documents and on the production of a booklet which aggregates cumulative guidance. The guidance itself is relatively clear and succinct. The only minor comment I would make is that the precise, simple recommendations often do not leap out from the page. A very minor stylistic change might make them more readily accessible to readers who merely skim the document.

2.  Has NICE ended confusion by providing a national single focus?

  With respect to our Trust, we clearly welcome guidance from NICE. A number of other bodies however also independently review the use of new drugs and developments in the NHS. These include:

    (a)  the hospital New Drugs Panel;

    (b)  the Ealing, Hammersmith, Hounslow Health Authority Priority Setting Sub Committee;

    (c)  the relevant sub committee of the Regional Specialist Commissioning Group.

  There appears still to be considerable confusion as to the roles of these different bodies in the light of NICE guidance. One of the problems is that NICE guidance is too long in coming, NICE addresses relatively few topics, and there are many items of business where decisions are required prior to deliberation by NICE.

3.  Is NICE providing guidance which is locally owned and acted on in the right way?

  There is general support for the process NICE uses to develop guidance. Most of the guidance is supported by the clinical community. There have been a number of exceptions. For example the guidance on glycoprotein inhibitors is not accepted by local clinicians who have produced a formal document defining the patient sub categories where they will follow the guidance and where they feel that the guidance should not apply. Similarly, there are many clinicians who feel that the limitation of access to a particular drug on the basis of cost benefit analysis is too stringent. They feel that there are subcategories of patients who would benefit greatly and should be offered the drug. Given the academic nature of the organisation, with its pronounced tendency to challenge any orthodoxy, it is however remarkable how much support in general, the guidance from NICE enjoys.

4.  Is NICE guidance actually promoting access by patients to interventions with good evidence of clinical and cost benefit?

  Patients have fast access to treatments known to work. Our organisation is very academic. Much of the research which NICE reviews is undertaken directly or indirectly by members of our organisation. Thus, for many of the interventions evidence has been reviewed locally and there has been a strong belief that these interventions should have been available many months or years prior to the final production of NICE guidance. A classic example of this is anti Tumour Necrosis Factor therapy for rheumatoid arthritis. This was developed in our institution and has been available to patients in research trials for many years. There has been great frustration that the processes for allowing this drug to be available on prescription have been so slow. There is concern that the time delay between development and introduction of a drug and the production of NICE guidance is too long. Many clinicians believe that the process of generating NICE guidance is one of rationing by delay, as opposed of one designed rapidly to introduce effective interventions.

January 2002

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