NICE aces Triennial Review but should it be scrutinised more often?

Following the publication of the results of the Department of Health (DH) review of the National Institute for Health and Care Excellence (NICE) in the UK, Leela Barham looks at how it fared and puts the case for more frequent examination.

NICE was one of the few arms-length bodies to make it through the Health and Social Care Act 2012 relatively unscathed. Aside from a name change – and the almost obligatory expansion of its remit to cover social care – the organisation came out looking much the same. That was in stark contrast to the changes wrought across the NHS elsewhere; depending on your viewpoint, these resulted in either the death of many previous agencies, such as Primary Care Trusts and Strategic Health Authorities, or the re-badging – albeit with a hefty bit of tinkering on roles and responsibilities – of many existing bodies.

No major changes for NICE

NICE also seems to have come out well from the DH’s Triennial Review, with no major changes proposed. That review started on 30 October 2014, with the results finally published on 20 July 2015.

The DH is NICE’s sponsor agency and has the, perhaps unenviable, task of holding NICE to account on behalf of government ministers. The Triennial Review is just one of the ways it does this. Essentially, these three-year reviews ask two key questions:

1. Do we still need the agency?

2. If so, is there anything that needs to change?

It was fairly obvious that NICE would always pass the first question; after all, the Health and Social Care Act 2012 put it on a firmer statutory footing, establishing it as an executive non-departmental public body (NDPB). This means that primary legislation is required before any future big changes can be made. It also reinforces NICE’s independence.

We should value that independence, and we should be cautious of too much interference from politicians, despite the temptation to call the Prime Minister or Secretary of State when dissatisfied with something NICE has done. NICE was set up, at least in part, to provide some much-needed distance from politicians, as well as to tackle ‘postcode prescribing’.

Whether NICE would easily pass close scrutiny around the second question was more debatable. NICE has faced heated criticism from a number of quarters, including some that were unexpected. Grumbles from patients, clinicians and, of course, industry are routine. And from the Daily Mail newspaper too. But more recently there have been scathing articles from academics too. For example, Karl Claxton and his colleagues suggest that NICE is under pressure and is already approving drugs where more health is likely to be lost than gained. They suggest that NICE is taking a direction where more harm than good is being done.

The DH states that ‘NICE performed well in the delivery of necessary functions and was highly valued by stakeholders’. It adds: ‘the tenor of the evidence gathered throughout the review was that NICE is a respected and valued organisation with an important role to play’. Most of the recommendations coming from the review simply build on what NICE already does, such as working in partnership with others in the NHS and involving patients.

One interesting suggestion is that NICE benchmarks itself against international comparators. The trouble with that is that there isn’t always clear consensus among the experts on the optimum composition of a health technology assessment anyway so it’s not obvious that NICE would necessarily be better, or worse, compared to others. However, learning from what others do well is a worthwhile endeavour and is already happening anyway.

Annual accountability

The recent Triennial Review is the first for NICE because it wasn’t a NDPB before 2013. That’s not to say that it wasn’t subject to scrutiny previously. For example, there was a World Health Organization review of NICE in 2006.

But, so far, NICE hasn’t been made subject to the annual accountability hearings of other NDPBs in the NHS. Big-hitting agencies including Monitor (the economic regulator), the Care Quality Commission (the quality regulator), the General Medical Council (the doctors’ regulator) and others have to face the Westminster Health Select Committee every year.

These annual accountability reviews are normally supported by a call for evidence. These evidence submissions are short documents, designed to focus people’s minds on the most important issues, and allow MPs to be briefed on what constituents think of the agencies that can seem like they’re operating in ivory towers.

If NICE were to receive such an annual review, it would serve to widen the annual accountability that already happens between DH and NICE anyway, as set out in their framework agreement, allowing others to bring their issues to the table.

NICE has some experience with the Health Select Committee, which has conducting ad hoc inquiries in the past. For example, in September 2014 it conducted a one-off oral evidence session to explore the work of NICE. In 2013 it reported on the results of a more detailed inquiry, covering the now defunct Value Based Pricing, as well as NICE’s work on Quality Standards, clinical guidelines, and its responsibilities on public health. In 2012 it also conducted a pre-appointment hearing with Prof David Haslam, now Chair of NICE.

So a move to an annual approach would, to a degree, just formalise scrutiny that has happened in the past, but would provide a predictable and formal way for patients, industry and anyone else with an interest – including academics with strong views – to table issues.

Given just how important the agency is – and not just for drugs – shouldn’t it, too, be subject to annual accountability reviews by the Health Select Committee even if it is not a formal regulator?

About the author:

Leela Barham is an independent health economist and policy expert who has worked with all stakeholders across the health care system, both in the UK and internationally. Leela works on a variety of issues: from the health and wellbeing of NHS staff to pricing and reimbursement of medicines and policies such as the Cancer Drugs Fund and Patient Access Schemes. Find out more here and you can contact Leela on leels@btinternet.com

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