Intended for healthcare professionals

Rapid response to:


Disinvestment from low value clinical interventions: NICEly done?

BMJ 2011; 343 doi: (Published 27 July 2011) Cite this as: BMJ 2011;343:d4519

Rapid Response:

Re: Do NICE's recommendations for disinvestment add up?

Dr Will Hollingworth, Reader in Health Economics and Dr Charlotte
Chamberlain, Public Health Registrar
University of Bristol

Garner and Littlejohns have encapsulated the difficulties faced by
NICE in identifying and recommending 'low-value' NHS activities from which
to disinvest. Disinvestment is challenging for any health system 1 and
NICE should be commended for its persistence in trying to address these
challenges on behalf of the NHS. NICE's disinvestment work has evolved
from developing de novo technology appraisals 2;3 and optimal practice
reviews 4 of specific technologies, towards a raft of initiatives
including hundreds of 'do not do' recommendation reminders drawn
predominantly from existing NICE clinical guidelines.

Despite these intensive efforts, there is limited and mixed evidence
that NICE disinvestment initiatives have been effective. 5;6 Furthermore,
NICE engagement workshops, which include a group of self-selected
individuals seeking opportunities for disinvestment as part of the QIPP
programme, tellingly revealed that many 'attendees were unaware of NICE's
do not do guidance or the recommendation reminders'. There are therefore,
clear weaknesses in the current processes for identifying, disseminating
and implementing areas for disinvestment.

We believe that NICE should reconsider the shift away from technology
appraisal of existing interventions and the reasons given for that shift.
The advantages of technology appraisal versus clinical guideline derived
disinvestment recommendations include: 1) their 'newsworthiness' aiding
dissemination; 2) the potential to focus on a limited number of the most
clinically and economically important decisions rather than risk
overwhelming PCTs and clinicians with hundreds of recommendations,
sometimes of little consequence; and 3) the doubts that have been
expressed about the ability of NICE clinical guidelines to adequately
account for cost-effectiveness 7;8 in every single recommendation that
they produce.
The fact that there are 'few identifiable candidates for total
disinvestment'9 needn't be a barrier. NICE technology appraisals of
innovations often do not recommend 'total investment' for all clinical
subgroups, instead where evidence is unconvincing NICE can reject or
approve conditional on further evidence development. An analogous
situation for disinvestment could see recommendations for research into
the use of existing interventions in clinical subgroups where
effectiveness and cost-effectiveness is doubtful and evidence is lacking.
Likewise, the worry that placing a spotlight on a particular, potentially
inappropriately used, health care intervention might prejudice views about
it isn't a strong reason for not doing so. 9 The appraisal, if done well,
will identify and synthesise all the evidence and all of us can adjust our
opinions in the light of it. The greater danger would be in not
challenging our pre-existing prejudices.

Perhaps the greatest challenge to technology appraisal based
disinvestment is in identifying potential candidates for partial
disinvestment. It has been previously noted that NICE met with initial
"enthusiastic backing for the idea of appraising existing technologies to
seek opportunities for disinvestment; but, when followed by requests for
specific suggestions, the subsequent silence has been striking. 10
However, a starting point might be to explore the diagnostic,
pharmaceutical and interventional procedures with the highest geographical
variation of use within the NHS. One potential source of variation is
differences among clinicians in their diagnostic thresholds or in their
belief in the value of the intervention, rather than any differences in
clinical need. 11 It has been argued that when evidence is not
compelling, geographic variation may represent legitimate differences in
patient preferences for a procedure or merely unimportant eclectic
practice by clinicians. 12 However, many NHS interventions are both
costly and invasive. Therefore, it seems reasonable that the onus should
be on clinicians with high intervention rates to demonstrate (by
participating in research) that their approach results in better patient
outcomes at an acceptable cost, rather than on NICE and PCTs to
demonstrate otherwise.

We believe that NICE should do more to encourage research into
interventions of uncertain cost-effectiveness and conduct more technology
appraisals of existing health care interventions. There is a need for
evidence-based disinvestment guidance which is appropriately engaged with
new commissioning structures in these challenging financial times.

Reference List

(1) Elshaug AG, Hiller JE, Tunis SR, Moss JR. Challenges in
Australian policy processes for disinvestment from existing, ineffective
health care practices. Aust New Zealand Health Policy 2007; 4:23.

(2) National Institute for Health and Clinical Excellence. NICE
Technology Appraisals- Wisdom Teeth Removal. 2000. 25-8-0011.

(3) National Institute for Health and Clinical Excellence. NICE
Technology Appraisal: Electroconvulsive therapy (ECT). 2003.

(4) Garner S, Pinwill N, Stokes T. National Institute for Health and
Clinical Excellence-Practice Review (OPR)-Tetracyclines for acne vulgaris.

(5) Cullum N, Dawson D, Lankshear A, Lowson K, Mahon J, Raynor P et
al. The Evaluation of the Dissemination, Implementation and Impact of NICE
Guidance. 2004. National Co-ordinating Centre for Research Methodology

(6) Okagbue N, McIntosh A, Gardner M, Scott AI. The rate of usage of
electroconvulsive therapy in the city of Edinburgh, 1993-2005. J ECT 2008;

(7) Wailoo A, Roberts J, Brazier J, McCabe C. Efficiency, equity,
and NICE clinical guidelines. BMJ 2004; 328(7439):536-537.

(8) Wonderling D, Sawyer L, Fenu E, Lovibond K, Laramee P. National
Clinical Guideline Centre cost-effectiveness assessment for the National
Institute for Health and Clinical Excellence. Ann Intern Med 2011;

(9) Garner S, Littlejohns P. Do NICE's recommendations for
disinvestment add up? BMJ 2011; 343(August 13):349-351.

(10) Pearson S, Littlejohns P. Reallocating resources: how should
the National Institute for Health and Clinical Excellence guide
disinvestment efforts in the National Health Service? J Health Serv Res
Policy 2007; 12(3):160-165.

(11) Wennberg JE, Barnes BA, Zubkoff M. Professional uncertainty and
the problem of supplier-induced demand. Soc Sci Med 1982; 16(7):811-824.

(12) Lilford RJ. Should the NHS strive to eradicate all unexplained
variation? No. BMJ 2009; 339:b4809.

Competing interests: William Hollingworth receives funding from the NIHR SDO programme for a project entitled: 'Using clinical practice variations as a method for commissioners and clinicians to identify and prioritize opportunities for disinvestment in health care.'

26 August 2011
William Hollingworth
Reader in Health Economics
Charlotte Chamberlain
University of Bristol, School of Social and Community Medicine