National Institute for Clinical Excellence
The Commonwealth Fund
Newsletter
December 2004
Issue of the Month: The British National Institute for Clinical Excellence
By Vida Foubister
The mission of U.K.’s five-year-old National Institute for Clinical Excellence is to create, disseminate, and foster implementation of standards of health care. There is no such model for national standards in the U.S. What can we learn from NICE?
Last February, the National Institute for Clinical Excellence (NICE)-a relatively new part of the British National Health Service (NHS) created to improve the quality of health care-released a clinical guideline on in vitro fertilization (IVF).
Surprisingly, there was little reaction among those affected even though the clinical guideline, like much of the guidance issued by NICE in the past five years, limited the care available through the NHS based on clinical as well as cost effectiveness. Specifically, the infertility guideline recommends that the NHS provide no more than three cycles of IVF to women between ages 23 and 39 as the clinical evidence shows a low success rate beyond those parameters.
Why was there no professional or public outcry? “We go through a very iterative process where we involve the main stakeholders,” explains Sir Michael D. Rawlins, M.D., a professor of clinical pharmacology at the University of Newcastle upon Tyne who has served as chairman of NICE since its inception.
NICE issues three types of guidance: technology appraisals of new and existing medicines, medical devices, diagnostic techniques, surgical procedures, and health promotion activities; clinical guidelines for the appropriate treatment and care of people with specific diseases and conditions; and recommendations on the safety and efficacy of interventional procedures, that is, predominantly new diagnosis or treatment processes that involve gaining access to the inside of a patient’s body, with or without cutting, and the use of electromagnetic energy or ultrasound.
Although the primary goal is to improve the standard of care received by NHS patients, cost effectiveness is a factor in the technology appraisals and clinical guidelines. Cost is not considered in the interventional procedure reviews.
Since January 2002, the NHS has been legally obliged to provide funding and resources for medicines and treatments NICE recommends as a part of the technology appraisals program. This means that, in some cases, the cost of medicines and devices NICE chooses not to approve are shifted to patients.
In addition, clinicians are wary of using interventional procedures that NICE deems unsafe.
Across the pond in the United States, there is no similarly focused federal agency and NICE’s approach appears to have attracted considerable interest-as indicated by the 10,000 daily hits on its Web site from U.S. visitors.
“We have something that looks somewhat analogous in many of the domains
in which NICE is working,” says Joseph Newhouse, Ph.D., professor of health care policy at Harvard Medical School… It’s just not “pulled together in one agency with a crisp mandate.”
(In the public and private sectors) there are a number of technology assessment groups that analyze drugs, devices, and procedures… There is another major difference between these groups and NICE-none of them explicitly considers cost effectiveness. “Right now, we’re not facing it. We’re making coverage decisions based on safety and efficacy; the costs are not supposed to enter into the decision,” says Victor R. Fuchs, Ph.D., Henry J. Kaiser, Jr., Professor Emeritus at Stanford University.
“You don’t hear a huge hue and cry in Britain through the media or the legal system [about] the fact that they’re doing this,” Fuchs continues. “England, apparently, is much more willing to come to terms with the fact that every health care system has to make some kind of rationed decisions.”
In the final analysis, it appears that both the United States and the United Kingdom are moving toward evidence-based medicine. The British model doesn’t have the duplication of effort seen in the United States and, as a result, is likely to be less costly. However, with the rapid evolution of medical technology, one concern with this approach, Neumann says (Peter Neumann, Sc.D., an associate professor at the Harvard School of Public Health), is “What if the government gets it wrong?”
http://www.cmwf.org/publications/publications_show.htm?doc_id=252181#issue
Comment: The health care system in the United States is unique in its continued acceleration in health care costs, primary related to ever greater utilization of high tech and specialized services, but without a demand from us for a commensurate increase in health care value.
In fact, the studies of John Wennberg and his colleagues have confirmed that regions with greater capacity and utilization of high tech, specialized services have not demonstrated significant improvement in health care outcomes. In fact, in some studies, greater spending has been correlated with lower quality care. And Barbara Starfield and colleagues have demonstrated that placing a greater priority on primary care services ensures higher quality at a lower cost.
Unfortunately, the issue is frequently framed as a need to ration services because of the limitations of our finite resources. The implication is that we should deny individuals of some highly beneficial services because we can’t afford to pay for all of them.
Rather than frame the debate as an issue over rationing, it would be much more instructive to frame the debate as to whether we should continue to allow unlimited funding of the large amount of care that is not beneficial and maybe even detrimental. Although the precise amount of funds that could be recovered has not been quantified, it is clearly in the hundreds of billions of dollars. If we were to decide that we would pay only for beneficial services, we could provide comprehensive care for everyone and actually reduce health care spending.
But I remain very dubious that fragmented, private and public sector efforts could accomplish this. There are too many vested interests that would continue to support the profound waste on which they thrive.
It’s time to get over the fear of the government bogeyman, and establish a single, public National Institute for Clinical Excellence. After all, Uncle Sam is our very own bogeyman, and we do have some control over him!