In pursuit of quality: the National Institute for Clinical Excellence

doi:10.1016/S0140-6736(99)02381-8

The Lancet

Volume 353, Issue 9158, 27 March 1999, Pages 1079-1082

https://doi.org/10.1016/S0140-6736(99)02381-8 Get rights and content

Summary

In the UK, as elsewhere in the world, there is abundant evidence of unacceptable inequalities and inefficiencies in health care. These failures are manifest in various ways including inappropriate variations in the uptake and use of health technologies of proven value, the too frequent failure to provide patients with optimum care for the treatment of common diseases, and the too ready adoption of health technologies with no established clinical benefits. Healthcare systems worldwide are therefore struggling to find ways to ensure that their health professionals are able to provide patients with the highest possible and affordable–standards of clinical care. The British government has committed itself to a programme of enhancing the quality of care given to National Health Service (NHS) patients. The new National Institute for Clnical Excellence (NICE) has been charge with providing NHS staff with clear and robust advice that will help them meet their own, and their patients', aspirations. The Institute's guidance will cover individual technologies as well as the management of a wide range of conditions. NICE will also advise on appropriate methods of clinical audit in those areas where it has provided guidance.

Section snippets

Background

There is abundant evidence that the clinical care we give our patients too often departs from best practice. The reasons for our failings—and, as a practising clinician, I readily include myself—are broadly four-fold. First, we sometimes adopt new health technologies into everyday clinical practice without adequate evidence of their clinical effectiveness or of their cost-effectiveness. Second, we are sometimes too slow to introduce new methods of practice even when they have been shown to be

Functions

NICE will have three broad functions:

•
Appraisal of new and existing health technologies.
•
Development of clinical guidelines.
•
Promotion of clinical audit and confidential inquiries.

The Institute's output—in the form of advice to health authorities, NHS Trusts, primary-care groups, and health professionals as a whole—will not be mandatory. There is an expectation, however, that its recommendations on technologies will be universally accepted. Its guidelines will cover most clinical

Appraisal

NICE will be expected to give advice on the clinical effectiveness and cost-effectiveness of both new and existing health technologies (including pharmaceuticals, devices, diagnostic tests, surgical procedures, and other interventions). As soon as the Institute is established, around 30 to 50 technologies a year will be selected (by the Department of Health) for appraisal by the Institute. The results will provide health professionals and health-service managers in health authorities, trusts,

Clinical guidelines

Clinical guidelines have been defined as “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances”.³ Clinical guidelines are neither cookbooks nor textbooks. But where there is evidence of variations in practice that affect patient outcomes, and a strong research base to support effective forms of management, clinical guidelines can help health professionals to provide the most appropriate care.

There is

Clinical audit

The Institute's guidance (from its Appraisal Reports and Clinical Guidelines) will be complemented by advice on simple methods of clinical audit that will enable clinicians, Trusts, health authorities, and primary-care groups to monitor their own performance. In turn, local clinical audits will help the Institute to revise, or improve on, the advice it gives. NICE will develop further the work of the National Centre for Clinical Audit, whose functions will be incorporated into the Institute.

The

Structure

NICE has been established as a Special Health Authority with a Board consisting of a chairman, seven non-executive members, and four executives. The backgrounds of the non-executives are intended to reflect both the scope and the geographical range (covering England and Wales) of the Institute's activities. The executives will include a chief executive, a clinical director, a director of communications, and a (part-time) finance director.

Although based in London, NICE will in many ways operate

Priorities

The past few months have been spent establishing the infrastructure for the new Institute. Now that the essential components are in place, the real work can begin. The Institute's highest priority must be to earn, and then retain, the confidence of health professionals, of patients and the public, of NHS managers, of the Government, and (ultimately) of parliament. To achieve this, NICE must meet four conditions:

(1)
secure broad technical competence;
(2)
establish effective dialogue with

Technical competence

It is axiomatic that the advice given by NICE to the NHS is robust, based on all the available evidence, timely, and relevant. NICE must ensure that there is transparency of its procedures and, in so far as is possible, that the evidence on which its advice is based is publicly available and accessible.

Nevertheless there will be difficulties. Even the most robust appraisals and clinical guidelines based on a rigorous and systematic review of all the relevant data must necessarily carry an

Dialogue

NICE will need to communicate with a range of organisations that includes the health professions, NHS managers, the health-care industry, and patients and their carers.

The health professions, both as individuals and as organisations, will have a central role in helping the Institute to disseminate advice of the highest quality. The support of NHS managers will be essential for ensuring that the Institute's advice is implemented. An effective partnership with the industries that produce health

Communications

Unless NICE can ensure that its advice is effectively communicated to the NHS, its staff, and its patients, the Institute's establishment will have been pointless. It is for this reason that the Institute will have, at Board level, a Director of Communications to develop a coherent strategy for ensuring that the NHS is fully aware of the Institute's output. Furthermore, the strategy must also ensure that communication is a two-way process; since health professionals and patients will have much

Value for money

NICE has been established neither to cut costs, nor to introduce rationing, but to help the NHS get value for money. Indeed, anyone who believes that NICE will reduce NHS expenditure is whistling in the wind. To ensure, for example, that hypertension in the community is recognised and adequately treated, will unquestionably increase the drugs' bill; and, in the short term, will increase NHS expenditure. In the longer term, however, it will decrease the NHS costs of caring for patients with

Conclusions

NICE is part (but only part) of the overall strategy for “clinical governance”. I am confident, given time, that it will be able to improve the quality of care that is given to patients in the NHS. To do so, though, it must engage the attention not only of its most obvious “stakeholders” but of all health professionals in the service. But do not expect too much too soon: NICE's first Appraisal Reports and Clinical Guidelines are unlikely to appear before the autumn, 1999.

Over the past few

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The NICE guideline implementation reduced the proportion of patients with STS who had undergone inadvertent excisions and residual tumour in re-resection specimens, indicating an improved pre-referral management of STSs.
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This process was supported by the government’s announcement of the Basic Policy on Economic and Fiscal Management and Reform 2018.10 Some countries have used HTA for listing or price negotiation, and it has also been used by authorities to call on manufacturers to submit cost-effectiveness data.11-15 In contrast, in Japan, almost all medicines are approved based on efficacy and safety data and are generally listed under public healthcare insurance within 60 days (90 days maximum) of their authorization.
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A key governance role is provided by the National Institute for Health and Care Excellence (NICE). Set up in 1999, NICE provides national healthcare guidance aimed at improving care and, ultimately, reducing healthcare inequalities and costs (Rawlins, 1999), however, the implementation and uptake of NICE guidance has been shown to be highly variable (Sheldon et al., 2004). Clinical guidelines constitute one type of NICE guidance, offering evidence-based recommendations for the care and treatment of specific conditions.
Clinical practice guidelines produced by NICE – the National Institute for Health and Care Excellence – are seen as key mechanisms to regulate and standardise UK healthcare practice, but their development is known to be problematic, and their adoption and uptake variable. Examining what a guideline or health policy means to different audiences, and how it means something to those communities, provides new insight about interpretive discourses. In this paper we present a micro-analysis of the response of healthcare professionals to publication of a single NICE guideline in 2009 which proposed a re-organisation of professional services for chronic non-specific low back pain. Adopting an interpretive approach, we seek to understand both the meaning of the guideline and the socio-political events associated with it. Drawing on archived policy documents related to the development and publication of the guideline, texts published in professional journals and on web-sites, and semi-structured interview data from professionals associated with the debate, we identify a key discourse that positions the management of chronic non-specific low back pain within physician jurisdiction. We examine the emergence of this discourse through policy-related symbolic artifacts taking the form of specific languages, objects and acts. This discourse effectively resisted and displaced the service reorganisation proposed by the guideline and, in so doing, ensured medical hegemony within practice and professional organisations concerned with the management of non-specific low back pain.
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Citation Excerpt :
A major focus on a reduction in waiting times for diagnosis and elective procedures substantially decreased the backlog of elective procedures.7,8 In 1999, the National Institute for Health and Clinical Excellence (NICE) was established to provide evidence-based guidelines for prevention, diagnosis, and treatment of major causes of disease and ill health and to disseminate standards for quality of care.9 Various types of incentive schemes have been tried to expand coverage of some key preventive interventions in primary care.10
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We used results of GBD 2010 for 1990 and 2010 for the UK and 18 other comparator nations (the original 15 members of the European Union, Australia, Canada, Norway, and the USA; henceforth EU15+). We present analyses of trends and relative performance for mortality, causes of death, years of life lost (YLLs), years lived with disability (YLDs), disability-adjusted life-years (DALYs), and healthy life expectancy (HALE). We present results for 259 diseases and injuries and for 67 risk factors or clusters of risk factors relevant to the UK. We assessed the UK's rank for age-standardised YLLs and DALYs for their leading causes compared with EU15+ in 1990 and 2010. We estimated 95% uncertainty intervals (UIs) for all measures.
For both mortality and disability, overall health has improved substantially in absolute terms in the UK from 1990 to 2010. Life expectancy in the UK increased by 4·2 years (95% UI 4·2–4·3) from 1990 to 2010. However, the UK performed significantly worse than the EU15+ for age-standardised death rates, age-standardised YLL rates, and life expectancy in 1990, and its relative position had worsened by 2010. Although in most age groups, there have been reductions in age-specific mortality, for men aged 30–34 years, mortality rates have hardly changed (reduction of 3·7%, 95% UI 2·7–4·9). In terms of premature mortality, worsening ranks are most notable for men and women aged 20–54 years. For all age groups, the contributions of Alzheimer's disease (increase of 137%, 16–277), cirrhosis (65%, −15 to 107), and drug use disorders (577%, 71–942) to premature mortality rose from 1990 to 2010. In 2010, compared with EU15+, the UK had significantly lower rates of age-standardised YLLs for road injury, diabetes, liver cancer, and chronic kidney disease, but significantly greater rates for ischaemic heart disease, chronic obstructive pulmonary disease, lower respiratory infections, breast cancer, other cardiovascular and circulatory disorders, oesophageal cancer, preterm birth complications, congenital anomalies, and aortic aneurysm. Because YLDs per person by age and sex have not changed substantially from 1990 to 2010 but age-specific mortality has been falling, the importance of chronic disability is rising. The major causes of YLDs in 2010 were mental and behavioural disorders (including substance abuse; 21·5% [95 UI 17·2–26·3] of YLDs), and musculoskeletal disorders (30·5% [25·5–35·7]). The leading risk factor in the UK was tobacco (11·8% [10·5–13·3] of DALYs), followed by increased blood pressure (9·0 % [7·5–10·5]), and high body-mass index (8·6% [7·4–9·8]). Diet and physical inactivity accounted for 14·3% (95% UI 12·8–15·9) of UK DALYs in 2010.
The performance of the UK in terms of premature mortality is persistently and significantly below the mean of EU15+ and requires additional concerted action. Further progress in premature mortality from several major causes, such as cardiovascular diseases and cancers, will probably require improved public health, prevention, early intervention, and treatment activities. The growing burden of disability, particularly from mental disorders, substance use, musculoskeletal disorders, and falls deserves an integrated and strategic response.
Bill & Melinda Gates Foundation.
Reflections: NICE, health economics, and outcomes research
2012, Value in Health

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