If hospitals or doctors were able to use any treatment or drug they wanted, they would be under huge pressure from the pharmaceutical industry to use freebies and trials. Someone, somewhere has to independently test whether a drug works and is safe to use.
Most advanced countries have an independent body or two testing the safety of drugs. NICE is the UK watchdog. NICE is an independent organisation responsible for providing national guidance on promoting good health and preventing and treating ill health. The government wants NICE to bring together knowledge and guidance on ways of promoting good health and treating ill health. NICE guidance applies to clinical guidelines, technology appraisals, interventional procedures and public health guidance.
Once NICE guidance is published, health professionals and the organisations that employ them are expected to take it fully into account when deciding what treatments to give people. However, NICE guidance does not replace the knowledge and skills of individual health professionals who treat patients; it is still up to them to make decisions about a particular patient in consultation with the patient and/or their guardian or carer when appropriate.
NICE does not license drugs or devices. Licensing drugs and devices in the UK is done by the Medicines and Healthcare products Regulatory Agency (MHRA). It makes sure that medicines, healthcare products and medical equipment are safe and do what they are supposed to do. Most licensed drugs and devices are assessed at a local level within the NHS, to decide whether local hospitals, GPs and health organisations will prescribe them.
While a drug or device is being appraised by NICE, NHS organisations should make decisions on its use locally, using their usual arrangements. A recommendation by NICE ends any uncertainty and inequality about prescribing. Once national guidance has been issued by NICE, it replaces local recommendations
So far, so good. But unlike similar bodies in other countries it does more than guide.
NICE reviews treatments to decide which are the most cost-effective and which NHS should pay for. A new drug has to offer value for money, if it doesn't, whether it is life saving or not, NICE won't approve it.
If NICE just approved quality and safety, everyone in the private hospital and insurance sectors would have an easier life, as the norm would be only to use NICE approved drugs. But as civil servants, politicians and the NHS duck the issue of what expensive drugs and medicines to use or not use, and effectively hide under the skirts of NICE, the current system causes dilemmas.
Most health insurers will pay for NICE approved drugs, and some will pay for some non-approved drugs. They are put in a position of either sticking with NICE approved ones only, and being accused of allowing customers to die or live in agony or live shorter lives than they could; or having to pay for drugs made more expensive as they are not being used by the NHS, and causing health insurance prices to rise. No insurer or private hospital should be made to play God.
NICE uses a metric called ‘quality-adjusted life year’, or Qaly, which grades a person's health-related quality of life from 0 to 1. Say a new drug for a previously untreatable condition comes on the market and the drug is proven to improve a patient's quality of life from .5 to .7 on the scale. A patient on the drug can expect to live an average of 15 years following the treatment. Taking the new drug earns patients the equivalent of three quality-adjusted life years (15 years multiplied by the .2 gain in quality of life). If the treatment costs £15,000, then the cost per quality-adjusted life year is £5,000.
NICE rarely approves a drug that costs more than £30,000 per Qaly.This helps the NHS reduce costs, but only at the expense of patients.
NICE approves over 90% of new drugs, and those it rejects are rarely life saving. But it has turned down some expensive treatments that prolong life such as the kidney cancer drug Sutent in 2008, angering patients and oncologists. The organization has since promised to approve more expensive life-saving drugs for illnesses affecting fewer than 7000 patients a year, but every few months they refuse to approve a drug that is being used in the private sector, purely on cost.
Because NICE is concerned about saving money and not what's in the best interest of the patient, its methods are prudent but unfair. No quango where we have no control should be allowed to put a price on whether you or I live or die.
NICE should be reformed so that it ONLY judges on safety and quality, leaving others to judge on cost. Doctors do this every day on other matters, so if we believe the politicians that doctors will get more say in what hospitals do, they should judge.
And if there is a new but very expensive drug, it should be up to politicians to decide if there is a way of doing a deal with the drug company to reduce the costs, or make the hard decision on whether the NHS should or should not use it.
Health insurance: Hot Topic: December 2009