The triumph of NICE

The National Institute for Clinical Excellence (NICE) and the Commission for Health Improvement (CHI) were both introduced in the NHS plan of 1998. Six years on, CHI is dead but NICE is conquering the world. NICE worked but “nasty” (as CHI was initially known) failed—perhaps because it wasn't nasty enough. NICE may prove to be one of Britain's greatest cultural exports, along with Shakespeare, Newtonian physics, the Beatles, Harry Potter, and the Teletubbies.

Cynical about government and trained to be sceptical, the BMJ was cautious in its welcome to NICE (BMJ 1999;318: 823). We believed that a body was needed to lead on rationing health care and were irritated that NICE insisted that it was nothing to do with rationing when it clearly was. To ration well it should, we insisted, look not only at new technologies but also at existing ones (BMJ 2000;321: 1363)—plus it shouldn't pretend that it could make its decisions simply on scientific evidence. It needed a way to assess social values.

Four years on we publish an article in which the gauleiters of NICE explain how they approach economic evaluation and have formed a Citizens Council to ensure that the values it uses in making its judgments “resonate broadly with the public” (p 224). It eschews, however, affordability. “Let them eat cake,” it may opine if cake is evidence based and socially valued. It is for government to decree that cake is unaffordable or for local health authorities to try to fund a little cake by cutting services for those too politically weak to protest. NICE, supported by its Citizens Council, has also decreed that “an additional adjusted life year is of equal value for each person.” Confronted with a grandmother and her granddaughter drowning you should toss a coin to decide which to rescue.

In a second article Alan Maynard and others argue that “NICE has yet to mature into the efficient prioritisation mechanism that is required to ensure the better use of NHS resources” (p 227). They insist that “the issue is not whether but how to ration.” The authors see four fundamental challenges for NICE. Firstly, “the government should make it impossible for the NHS to adopt expensive new technologies until they are approved by NICE.” Secondly, NICE should more explicitly recognise the equity dimension of health care, perhaps adopting “the fair innings approach” that would leave the grandmother drowning. Thirdly, it must consider old as well as new technologies, and, fourthly, a way must be found to constrain the health inflation it is causing—perhaps by giving NICE a real budget.

Four years ago the BMJ proposed some characteristics for NICE. We can now attach provisional scores. “Britain,” we concluded, “would benefit from a body that admits it is about rationing (2/10), works openly (5/10), uses evidence (8/10), looks right across health care (2/10), incorporates ethical thinking systematically into its judgments (6/10), is more distant from politicians and the pharmaceutical industry (3/10), and is directly accountable to the public (1/10).” “Satisfactory, but could do better,” writes the retiring headmaster.