The secrets of NICE success

To write in praise of a public body always carries a risk. That what you are doing is a curse. The Audit Commission’s independently written but self-commissioned history of its existence up to 2008 was followed in 2010 by the decision to abolish it.

So it is to be hoped that a short history of NICE – the National Institute for Health and Care Excellence – does not have the same effect. Telling its story, however, felt well worth doing because this month [April] NICE celebrates its 17^th birthday and it is about the only arm’s-length body that Labour created in health and social care to have survived with its essential remit intact – despite the fact that it has lived amid almost constant controversy.

By recommending which new technologies – chiefly, as far as the media is concerned, which new drugs – the NHS should and should not adopt, it has shielded ministers from these difficult, and indeed sometimes heart-wrenching, decisions. Over the years, it has been damned for ‘sentencing patients to death’ when it has rejected treatments that it judged insufficiently cost-effective. It has been praised as one of Britain’s greatest cultural exports – other countries have learnt from NICE. It has been lauded by some health economists, but damned by others. So it is worth asking why it has survived.

One reason lies in the simple fact that its essential remit has remained intact. The core of its business has remained health technology assessment and the production of guidelines on best clinical practice. A second may well be that it operated from the start on a set of declared principles: robust, inclusive, transparent, independent and contestable. It has applied a declared set of social values to its judgements. And it has used, imaginatively, an independently-run citizens’ jury approach to inform those judgements. It has always offered an appeal mechanism. As a result, as Sir Michael Rawlins, NICE Chair for its first 13 years, has put it, everyone has been able ‘to have their say, if not necessarily have their way.’

Its longevity can’t be assessed without a look at the personalities involved and their longevity. Frank Dobson, the  Health Secretary who appointed him, says Rawlins proved to be ‘clever, charming and tough as old boots’ and that ‘so much of NICE’s success was down to him personally.’ Rawlins proved adept at handling the politics – politics with the pharmaceutical industry, with politicians, with patient groups. Sir Andrew Dillon, Chief Executive since its inception, brought not just managerial skills but the intellect to contribute to the difficult decisions NICE had to make. Other early, long-lasting, appointments were also crucial. The people in this story mattered.

NICE has partly survived because, at least up to now, the institutional memory in the Department of Health has been strong enough to explain repeatedly to incoming ministers what it is there for. So, repeated ministers have allowed it do the job for which it was created. Only twice has that come under threat. The biggest threat to its existence was David Cameron’s creation of the separate Cancer Drugs Fund which now, six years late, is coming home, so to speak. NICE will again (it never quite lost the role entirely) decide the ‘yes’ or ‘no’ or ‘only in some circumstances’ rulings on cancer drugs.

All that said, it faces some big challenges. Like so many successful bodies, NICE has been subject to ‘mission creep’ – ministers, judging it to be successful, have repeatedly added new roles. Too many of them to detail here. But the addition of public health to its remit does mean that instead of simply telling the NHS what it should do, it is now advising ministers and local authorities on public health initiatives. Neither of which are bound by that advice. If they come to reject NICE’s recommendations repeatedly, that may undermine the body’s broader authority. And the same may apply to its newest area of activity – social care – where, again, there is no mechanism to ensure its recommendations are adopted.

NICE recommends whether something is sufficiently cost-effective to be adopted. But it was always left to ministers – and now to NHS England as well – to decide whether that was then affordable. Cash for the NHS is now immensely tight. There has already been the odd instance of funding for a recommendation being delayed on the grounds of cost. If that happens repeatedly, it could lead people to ask ‘what is the point of NICE?’

So, it faces these and other challenges, some of which have brought down other, once successful, arms-length bodies. But that still leaves it with a birthday worth celebrating.

Download A Terrible Beauty: A Short History of NICE, by Nicholas Timmins, Sir Michael Rawlins and John Appleby.