Is NICE delivering the goods?

Has NICE got it right? An international perspective considering the case of Technology Appraisal No. 98 by the National Institute for Health and Clinical Excellence (NICE)

BACKGROUND

The National Institute for Health and Clinical Excellence (NICE) has been widely recognised as setting an international standard for high-quality health technology assessments (HTAs) including economic evaluation.

SCOPE

A previous critical analysis of NICE Technology Appraisal No. 98 (TA98), evaluating methylphenidate, dexamphetamine and atomoxetine for the treatment of attention-deficit/hyperactivity disorder (ADHD) in children, revealed a number of issues, which must cast doubt on the robustness of the NICE approach when addressing a complex clinical decision problem. The exploration of potential underlying problems will be followed by a discussion of lessons for international healthcare policy-makers, and is intended to be an invitation to further debate and inquiry, not a presentation of definitive conclusions.

SYMPTOMS

Pertaining to the technology assessment report, potential problems were identified relating to an unnecessarily narrow scope, data search and selection strategy, the distinction between efficacy and effectiveness, data synthesis across studies and clinical effect measures, and limitations of the economic model. The appraisal process moderated the asserted 'clear conclusions' of the assessment but could not compensate for some of its gaps.

CONCLUSIONS

It is suggested that key issues contributing to these problems may have included a separation of clinical and economic perspectives, a highly standardised reference case analysis that was followed schematically, the absence of an effective system for quality assurance of technology assessments, and transparency deficits of the economic evaluation. Further considerations for international policy-makers looking at NICE as a potential role model for HTAs are discussed, such as institutional context, the objectives of collectively financed healthcare and related value judgments, the reliance on QALYs as a universal and comprehensive measure of health benefits, the appropriate perspective for analysis, and process-related implications.

NICE accountability for reasonableness: a qualitative study of its appraisal of treatments for attention-deficit/hyperactivity disorder (ADHD)

OBJECTIVE

The UK National Institute for Health and Clinical Excellence (NICE) is widely regarded a role model for the implementation of Health Technology Assessments including cost-effectiveness evaluation. The aim of the present study was to explore the real-life robustness of the NICE technology appraisal process when addressing complex clinical problems, using the Accountability for Reasonableness (A4R) framework proposed by Daniels and Sabin as a reference.

METHOD

A qualitative case study of NICE Technology Appraisal No. 98, 'Treatments for Attention-Deficit/Hyperactivity Disorder (ADHD)', analyzing each step of the appraisal process.

RESULTS

Scoping was narrower than that for corresponding clinical guidelines. Economic evaluation for assessment was primarily based on six short-term studies, was unable to differentiate compounds on grounds of effectiveness, and cost-effectiveness modeling suggested a clear recommendation driven by acquisition costs. After appraisal, all treatment options assessed were recommended within their licensed indications. With estimated costs per quality-adjusted life years (QALYs) compared to no treatment generally falling below 7000 pounds, NICE guidance specified that choice of drug should be primarily based on clinical considerations, followed by cost.

CONCLUSION

The appraisal process adhered to predefined timelines, which were sensibly adapted by NICE to changes in the environment. A4R criteria most pertinent to the case study were 'publicity' and 'relevance'. The 'publicity' condition was greatly fulfilled, except for commercial-in-confidence data and economic model. 'Relevance' requires appraisals to reflect concerns for fairness and to be evidence-based; in that respect, principles and realization of the assessment deserve further scrutiny. Questions also remain regarding the 'appeal' and 'enforcement' conditions under A4R.

Regulating pharmaceutical markets: improving efficiency and controlling costs in the UK

UK government policy on pharmaceuticals is broadly integrated across the whole of health care policy. In the early 1990s, cost containment was emphasized, through budget holding by doctors to ensure clinical acceptability. From 2000 onwards, increased government funding for the NHS has allowed expansion of services and prescribing in areas of public health importance, but has been coupled with increased accountability and ambitious targets for the process of care and health outcomes. Standards for care are set in national guidelines including those from the National Institute for Clinical Excellence (NICE). NICE recommends or rejects new technologies to the NHS for their clinical value and cost effectiveness. Although following its advice is mandatory, evidence so far suggests that it has been only partly successful at improving services and eliminating variations. GP prescribing is monitored by Primary Care Organisations (PCO) which also hold the medicines budget. They may provide incentives to GPs for meeting targets in quality or expenditure. The UK government regulates the prices of generics but not of branded medicines; instead it regulates the profitability of the pharmaceutical industry. This arrangement seems to have been successful both at maintaining a major employer and export earner, and in limiting high drug expenditure.

Economic issues in access to medications: schizophrenia treatment in England

Mental health problems and the services to address them are currently receiving more attention in the UK than ever. Mental health care in England--indeed, across the UK--is experiencing a much needed transformation. It is therefore highly pertinent to examine the patterns of psychotropic medication use, given their intended links to recovery, rehabilitation, and reintegration, as well as to explore the economic and other factors that appear to influence those patterns. These are the aims of this paper. Our attention will be primarily focused on England. What this analysis shows is that given a higher profile by government, including additional funding (although not really benefiting differentially compared to other parts of the health service) and the first national service framework, it is possible to see changes in service patterns, access and (to a degree) outcomes. These changes are occurring at a time when new classes of psychotropic medication are being introduced in a range of therapeutic areas, contributing to the relatively rapid growth of take-up but also raising questions about appropriateness, effectiveness, cost-effectiveness and equity.

The English National Health Service: 1979--2005

This article aims to assess the development of the English National Health Service (NHS) over the period 1979--2005, against the original, and often repeated, core objectives of the system: that it be universal in offering coverage to all members of the population in times of health care need; that it be comprehensive in its provision of health care services; and that it be (largely) free at the point of use. Comprehensiveness is open to interpretation, and may depend upon the wealth of the nation. Universality and (largely) free care at the point of use, which lend themselves to the principle of equal access for equal need, are more concrete, and it is not difficult to ascertain if they have been substantially and/or systematically violated. The article details briefly the developments in resource allocation, provider payment mechanisms, incentives and accountability, and notes that much of the emphasis on health sector change since the mid 1980s has been placed upon improving supply side efficiency and reducing waiting lists/times. Improving NHS efficiency, and indeed related aspirations associated with choice and health outcomes, can be perceived as 'secondary' objectives, in that they should not serve to undermine the core objectives of the system, assuming that the security offered by having an accessible, universal health care system is considered worthy of protection. The overall conclusion is that the NHS has performed quite well against its core objectives to date, although it is possible that the current preoccupation with choice and health outcomes will lead us down a different policy path in the future.