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Chairman of NICE admits that its judgments are hard to defend

BMJ 1999; 319 doi: (Published 06 November 1999) Cite this as: BMJ 1999;319:1222
  1. Gavin Yamey
  1. BMJ

    Professor Sir Michael Rawlins, chairman of the National Institute for Clinical Excellence (NICE), has admitted that its decisions are “questions of judgment, difficult to defend, difficult to teach.”

    Speaking at a conference entitled “Medicine in the Millennium: confronting the issues,” jointly organised by the Royal College of Physicians, the Royal College of Surgeons, and the Royal Society of Medicine, Professor Rawlins discussed how the institute will have to balance clinical and cost effectiveness. “The most important criteria is the clinical need of patients,” he said, “but this must be considered in relation to the severity of the disease or condition, the benefits and costs of existing treatment, and the incremental benefits and costs of the new treatment under consideration.”

    For any new treatment, the institute will make one of four proposals. Three of the options centre on recommending using the treatment: general use for established indications; restricted use for particular groups of patients to maximise clinical and cost effectiveness; or limited use, only in the context of formal trials. The fourth option is to advise doctors not to use the treatment at all, as happened with the novel flu drug zanamivir (Relenza), though there is currently no legislative power behind this advice (16 October, p 1024).

    Professor Rawlins was criticised by conference participants for being distanced from patients, who may demand new treatments in their GP surgeries “Doctors have a second responsibility,” he argued, “not only to the patient in the surgery, but to those in the waiting room. We operate a fixed budget, and we have to use this in 0a cost effective way. If we don't do this according to NICE, we will move to a situation like that in the United States, with its health maintenance organisations.”

    Commenting specifically on NICE's rejection of zanamivir on grounds of cost, he said: “It wasn't the cost in terms of pounds, shillings, and pence, it was the cost in terms of demands on primary care.” He admitted that all decisions in the future will be based on difficult judgments, which have “no mathematical quantitative approach,” and emphasised the importance of considering the other ways in which money could be better spent, which he called “opportunity costs.”

    But Dr Robin Fox, editor of the Journal of the Royal Society of Medicine, argued that there is a lack of transparency in considering such opportunity costs. He asked: “How is the money saved by not recommending Relenza going to be spent? How do we know that it will not be used to buy another bomb?”

    The secretary of state for health and the national assembly for Wales have asked NICE to bring forward its appraisal of the taxane family of drugs, used to treat breast and ovarian cancer. Andrew Dillon, chief executive of NICE, said: “The new secretary of state has placed the causes and treatment of cancer at the top of his agenda. NICE is pleased to have been asked to respond and play its part in addressing this national priority.”

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