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
(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
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
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.