NICE work if you can get it

Detailed knowledge of NICE's quest for value in the NHS will stand advisers in good stead

Access denied. That is the implication of recent developments in healthcare policy. The public’s satisfaction – or otherwise – with the NHS has always been an indication of how it feels about the incumbent government.

The UK healthcare climate has alw­ays been dynamic and never more so than in the past ten years. But now we are in the throes of another change of direction, which arguably threatens the founding principles of the NHS and could propel health to the top of the general election agenda.

In this environment, it is insufficient to be a public affairs specialist. An effective practitioner needs a comprehensive understanding of the NHS market, the broader policy-making framework and, crucially, the frontline NHS.

Since 1997, successive Labour governments have introduced – then quietly dropped – a plethora of healthcare quangos, initiatives and programmes. Who remembers Health Action Zones, the Commission for Health Improvement and Healthy Living Centres?

The National Institute for Health and Clinical Excellence (NICE) is one Labour creation that has bucked the trend. From April, the Government’s ‘cost watchdog’ will assume a wider remit: it will develop the indicators that incentivise GPs’ prescribing behaviour and will oversee web-based information service NHS Evidence.

NICE’s expansion is a symbol of the current driver in the NHS – value. And when value is concerned, political, NHS and commercial interests tend to converge. Manufacturers are increasingly negotiating novel risk-sharing schemes with the Department of Health as a prerequisite to securing NHS access for their products.

But this puts the Government on a collision course with an NHS founded on the principle of uniform, universal access to healthcare free at the point of delivery. NHS patients have come to
expect – and demand – high quality care and access to treatments, irrespective of cost. NICE’s decisions have frequently been controversial, precisely because they highlight the need to prioritise the allocation of finite NHS resources.

Cost and value are also important to patients. The idea that NHS patients might be allowed to ‘top up’ their care with personal funds dominated the latter part of 2008, after NICE, in a draft recommendation, decided not to app­rove four kidney cancer drugs for NHS funding. The cancer tsar’s report proposed a novel solution: patients would be allowed to top up their NHS care, the quid pro quo being that NICE would find a way to recommend more treatments, limiting the number of situations in which a top up would be needed.

Devolution adds another layer of complexity to the value question. The Scottish Government is maintaining the philosophy of a ‘mutual’ NHS, but is coming under increasing pressure to introduce value-driven risk-sharing programmes to improve access.

It is worth speculating how NICE would fare under a Conservative government. Shadow health secretary
Andrew Lansley has proposed that NICE should have a role in setting drug prices, with medicines priced according to the value they deliver to the NHS.

The question of value will undoubtedly dominate 2009. Having detailed and up-to-date knowledge of the interplay between commercial, NHS and political drivers are crucial. As doubts increase about the sustainability of Bevan’s 1948 model, we should ask whether Gordon Brown, if he had the chance to create a national health service from scratch, would want to start from here.

Views in brief
What effect would a compulsory register of lobbyists and clients have?
If the aim is to ensure transparency and openness, that is appropriate. The APPC register exists for that purpose. If the register were limited to commercial lobbying firms, they are only a minority of those who lobby. To suggest that registration could confer some privilege is unacceptable and undemocratic.

Your yacht is moored off Corfu but Mandelson, Osborne, Rothschild and Deripaska aren’t available. Who is on your fantasy guest list?
King Charles II, astronomer Carl Sagan, runner Paula Radcliffe and Bon Jovi guitarist Richie Sambora.

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