Wednesday, 2 June 2010

The NICE Knight

Sir Michael Rawlins has been chairman of the National Institute of Health & Clinical Excellence (NICE) since its formation in 1999. He was knighted in June 1998 so it can not be said that his knighthood resulted from his role at NICE. What can be said is that, since he has been the only chairman, NICE must have developed into it’s present form greatly influenced by him.

NICE is never going to please everyone, since its role is to obtain value for money in the NHS and inevitably some treatments will fail to meet the (arbitrary) figure of £20,000 per year or less for a Quality of Life Year. This does not mean that the treatments are ineffective, only that they represent, in the estimation of NICE, poor value for money. To complicate matters further many PCTs regard the £20,000 figure as far too high.

A great deal of what is said about NICE is mythology. For example Trusts will often hide behind NICE and refuse a certain treatment because it is “not NICE approved” as if this constitutes some sort of ban. “Not approved” does not however mean “disapproved” and the Department of Health has said that it has 'made it clear to PCTs that funding for treatments should not be withheld simply because guidance from NICE is unavailable. Sir Michael himself has pointed out that there are no penalties on doctors who fail to follow recommendations.

On the other hand some treatments are applied far more commonly than NICE guidelines support. A good example of this is the guidelines for Statin use. If you read these it becomes clear that many patients receive statins in spite of the guidelines, not because of them.

Probably the greatest error of NICE was in it’s formulation of guidelines for the treatment of chronic back pain. David Colquhoun has summarised this fiasco far better than I could, but to take one small quote, “The panel consisted of a surgeon, psychologist, osteopath, acupuncturist a physiotherapist and an academic; not one pain consultant!” The presence of quacks on this panel, is inexcusable and is a decision for which Prof Rawlins must take responsibility, as is the endorsement of therapies unsupported by a jot of evidence. Further the calls for the guidelines to be recalled and completely redrawn have been completely ignored.

NICE have also started to intrude into areas arguably beyond their original remit as shown here.

So, is Sir Michael Rawlins a worthy Knight or a suit full of bugger all?

Certainly much of clinician dissatisfaction with NICE is based on misunderstanding of the level of authority conferred on NICE by others. To be fair Prof Rawlins has attempted to put the role of NICE in perspective as seen here. This excellent article highlights the role of clinical judgement, complemented by but not dictated by evidence.

This article alone, in my view, sets Prof Rawlins more to the worthy Knight end of the spectrum.

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