Reply from chairman of NICE

EDITOR—Restrictions on space prevent me replying here in full to Smith's editorial1; my complete response is published on the National Institute of Clinical Excellence (NICE) website (http://www.nice.org.uk/).

The institute's purpose is to offer health professionals guidance on the use of technologies, based on rigorous reviews of the available evidence for clinical and cost effectiveness. In doing so, it takes the following six matters into account:

• The clinical needs of patients in relation to other available technologies; this is an overriding issue, where the evidence base for clinical effectiveness is crucial

• NHS priorities; this is a relative, but not an absolute, criterion

• The broad balance between benefits and costs, incorporating both clinical and cost effectiveness

• The potential impact on other NHS resources

• The encouragement of innovation

• Guidance from ministers on the resources available.

The last point exists should it be required; the institute has not yet received any such guidance. In the event that a technology meets the institute's appraisal criteria but is unaffordable with the resources available, it is a matter for parliament, not the institute, to decide resource allocations. If the institute were to be given such advice on resources, the transparent process that we follow (see http://www.nice.org.uk/) ensures that it would be apparent.

Issues about cost effectiveness inform, but are not the sole determinant of, the institute's guidance. The institute seeks evidence from, consults with, and offers the right of appeal to professional and patient organisations while developing its guidance. The appraisal committee's members (who include patient representatives) are entirely independent and could not, as Smith insultingly alleges, be manipulated by “nods and winks.” The NHS Plan indicated that the institute should in addition establish a citizen's council, which will inform value judgments, such as the priority that the NHS should give to future guidelines …