Select Committee on Health Appendices to the Minutes of Evidence


Memorandum by the British Medical Association (NC 18)


  1.  The British Medical Association is a professional association representing the interests of doctors throughout the country. It is also an independent trade union, an educational and scientific body, and a publishing house. Its views are based on the practical experience of its members—80 per cent of doctors practising in the UK.

  2.  The BMA was originally supportive of the establishment of NICE, and we continue to believe that it fulfils an essential function and helps to contribute to the prioritisation of resources. Our comments below are intended as constructive criticism and should be taken in the context of overall support for NICE.


  3.  In general we are satisfied with the clarity and credibility of guidance issued by NICE. However, it has been criticised in the past for a lack of openness and clarity in its assessment procedures[1]. In particular, the reversal of its decision on zanamivir (Relenza) was widely seen at the time as influenced by pressure from the pharmaceutical industry[2].

  4.  Such perceptions inevitably call into question the credibility of the guidance issued by NICE and ultimately of the organisation itself. It is vital therefore that the assessment procedures followed by NICE continue to be both rigorous and transparent, that its performance is monitored to ensure that it is kept free of external interference and that it does not come under political pressure to develop covert rationing decisions.

  5.  We are concerned that the work programme of NICE is largely set by Ministers and is therefore influenced by the need for political solutions. NICE itself should determine its priorities, drawing on public and professional concerns where appropriate. It must become responsive to important therapeutic advances to enable doctors to prescribe effective new treatments without undue delay. In this way, it would often be able to address issues before they became overly politicised.


  6.  Although the establishment of NICE was intended to eradicate "postcode prescribing", its success in doing so has been constrained by the ability of individual health authorities and primary care trusts to determine whether to implement its guidance locally. Many are guided in their decisions by pressure on resources and the need to cut budgets. As a result, the issuing of national guidance by NICE has had little effect on regional variations in the availability of treatment.

  7.  The BMA welcomed the recent announcement by Lord Hunt that, from January 2002, health authorities and PCTs will be obliged to fund treatments recommended by NICE. This should help to provide a single national focus. However, extra funding must be made available for these treatments to ensure that other areas of healthcare are not starved of resources as a result.


  8.  There is an inherent contradiction between the concept of local ownership and that of a single national focus. Until now, the latter has been subject to local decisions on whether to implement NICE guidance. This area of local decision-making will no longer be available and it is not clear how the goal of local ownership will be achieved in the future. More explicit guidance on the scope of local ownership would be useful.

  9.  We are particularly concerned that PCTs' budget decisions will be driven largely by the recommendations of NICE and the requirements of national service frameworks, leaving very little scope to invest in locally-determined priorities or resolve local problems with local solutions. We are already aware of many cases in which overspending on prescribing budgets has resulted in pressure on other areas of expenditure. Again, sufficient resources to implement NICE guidance without detriment to other areas of healthcare is the most important factor.


  10.  NICE guidance is generally well received and supported. Our only concern in this area is that cost-effectiveness can be very difficult to determine and that this factor is often not included in NICE appraisals. Ideally this assessment would incorporate, in addition to a measure of cost per quality adjusted life year (QALY), subjective criteria such as ethical and value judgements. For example the controversy over the use of beta-interferon for multiple sclerosis sufferers has highlighted the importance of consulting users.

  11.  The recently announced establishment of a citizens council should do much to ensure that subjective criteria are considered. We hope that NICE also continues to develop rigorous methods of assessing cost-effectiveness in terms of cost per QALY.

1   Kmietowicz Z. Reform of NICE needed to boost its credibility. BMJ 2001 (323:1324). Back

2   Smith R. The failings of NICE. BMJ 2000 (321:1363-1364). Back

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