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Editor's Choice

NICE at 10

BMJ 2009; 338 doi: (Published 29 January 2009) Cite this as: BMJ 2009;338:b344
  1. Fiona Godlee, editor, BMJ
  1. fgodlee{at}

    NICE (the National Institute for Health and Clinical Excellence) is 10 years old. Controversial from its inception and constantly in the public eye, NICE’s survival alone is surely something to celebrate. A search on for the past 10 years finds the institute mentioned in three articles a week on average. Looking back over this coverage, my sense is that the BMJ has shown support for NICE by being a critical friend. This week we continue that tradition with a cluster of articles challenging NICE on several fronts, as well as a podcast interview with its chief executive Andrew Dillon ( NICE’s chairman Michael Rawlins has been shortlisted for the BMJ Group’s lifetime achievement award (doi:10.1136/bmj.b275). You can vote for the winner on

    So what are some of the challenges facing NICE? One is its arbitrary threshold for deciding which drugs are cost effective enough for the NHS to pay for. This situation hasn’t changed in the past 10 years. In our head to head (doi:10.1136/bmj.b181) Adrian Towse argues that the threshold is now putting the UK behind countries with the same per capita healthcare spending. He thinks NICE should base its decisions on the public’s willingness to pay. But James Raftery argues convincingly that far from being raised the threshold should be lowered if fixed budgets are not to be blown (doi:10.1136/bmj.a3056). Both commentators ask what NICE is doing about disinvestment—that is, stopping the NHS from paying for less cost effective interventions already in use. They also ask how many interventions of equal or greater cost effectiveness are displaced by the need to fund what NICE approves.

    In a separate article (doi:10.1136/bmj.b67), Raftery argues that NICE’s recent concession on expensive cancer drugs for people at the end of life will do little to increase the availability of these drugs. They will still fall foul of the criterion that there should be no alternative treatment with comparable benefits. Jane Speight and Matt Reaney want to see NICE take more account of patients’ perspectives rather than relying mainly on the values of the general population (doi:10.1136/bmj.b85). Michael Drummond and Anne Mason question the way NICE handles drugs for which companies submit no evidence (doi:10.1136/bmj.a3182). At the moment NICE makes no recommendation in these cases but allows the drugs to be funded, creating a perverse incentive for companies to withhold evidence.

    NICE is a national treasure. It needs critical friends. Perhaps beyond sheer survival the clearest signs of its achievement over the past 10 years are its undiminished unpopularity with the drug industry and its growing popularity with governments around the world. As Nigel Hawkes quips in his report on NICE’s global expansionism (doi:10.1136/bmj.b103), “the drug industry would love to have exported it, preferably somewhere like Mars.”


    Cite this as: BMJ 2009;338:b344

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