Memorandum by the Health Technology Board
for Scotland (NC 40)
1. SUMMARY AND
1.1 The Health Technology Board for Scotland
(HTBS) welcomes the House of Commons Health Select Committee's
inquiry into NICE to consider the progress NICE has made in achieving
the key goals envisaged in A first class service.
1.2 HTBS was created in April 2000 as a
special Health Board to provide advice to NHSScotland on the clinical
and cost effectiveness of new and existing health technologies.
HTBS may be regarded as NICE's counterpart in Scotland with regards
to its work on Health Technology Appraisals and so these comments
relate solely to this aspect of NICE work. HTBS recognises that
NICE does much valuable work in other fields, but has little detailed
experience of this.
1.3 HTBS undertakes its appraisals in a
slightly different manner from NICE: undertaking broadly scoped
appraisals, performing technical work in-house, using topic specific
experts for interpretation of evidence in a Scottish context,
using open consultation and clarification rather than appeal meetings
to resolve issues. Despite these differences in process, HTBS
has established a strong working relationship with NICE and has
valued the opportunity to share expertise, experience and appraisals
work. NICE has acted as a mentor to HTBS in many situations and
it is interesting to see alternation in some of the NICE processes
to be more in line with the Scottish model (eg open consultation).
1.4 Scotland has particularly valued the
close collaboration established between HTBS and NICE to contextualise
the NICE appraisal guidance for Scotland, thus extending its impact
across the border. This unique liaison has been recognised as
a role model for other Agencies within the UK and EU and HTBS
looks forward to even greater collaboration and joint working
on full appraisals in the future.
1.5 Overall, it is clear that NICE is recognised
as a world leader in production and delivery of appraisal guidance.
Its impact on policy and ability to change healthcare practice
is envied by many well-established EU Health Technology Assessment
2.1 NICE has established itself internationally
as a scientifically credible organisation and this is demonstrated
by their membership of the International Network of Agencies of
Health Technology Assessment (HTA).
2.2 NICE was the first appraisal organisation
to take evidence from all stakeholders (few organisations involve
manufacturers or patient groups). Such broad consultation creates
credible guidance, but provides challenges about collation and
interpretation of qualitative and quantitative evidence. The members
of the NICE appraisal committee, its HTA report contributors and
NICE appraisal staff are driving forward new developments in appraisal
methodology to ensure that their advice is scientifically robust
and can withstand the substantial challenges that arise from broad
2.3 Value judgements are a fundamental part
of a Health Technology Appraisal, but to produce clear guidance
it is essential to make the basis for value judgements transparent.
This is difficult to achieve and an area with which all appraisal
Agencies struggle. NICE has tried to make their rationale clear
in the appraisal guidance documents, whilst recognising that healthcare
decision makers are overloaded with information.
2.4 Recommendation: The Committee
may wish to take account of the international standing of NICE
and benchmark its activities against other European HTA Agencies.
3. ENDED CONFUSION
3.1 The close working relationship established
between NICE and HTBS avoids the confusion of duplication and
conflicting advice. The outputs of this collaboration are explained
elsewhere in this document, but examples of the cooperation that
lead to a shared but contextually appropriate advice in Scotland
Continual communication between senior, technical
and scientific staff from NICE and HTBS including:
Sharing of information re publication
timetables and controversial issues arising from assessments.
Discussion of potential topics to
be assessed by each organisation to avoid duplication and allow
collaboration where appropriate.
HTBS involvement as consultee in
all appraisals, with input of Scottish experts.
NICE sign-off on all HTBS Comments
Ground-breaking discussions about
Sharing of methods for interactions
with stakeholders: manufacturers, patient groups and NHS professionals.
Reciprocal attendance of Chief Executives at
Invited presentations by NICE/HTBS at international
meetings organised by HTBS/NICE.
4.1 Whilst NICE's remit for Technology Appraisal
Guidance extends only to England and Wales, its impact extends
to Scotland. During 2001, clinicians and managers in NHSScotland
discussed NICE Guidance with colleagues in England and Wales and
began to ask what the status of NICE Guidance was in Scotland.
Consequently, HTBS agreed to "Comment" on all NICE guidance
published after 1 May 2001. NICE Appraisal Guidance is now issued
in Scotland with either a covering letter or a printed booklet.
4.2 HTBS accepts the scientific rigour of
NICE Guidance and does not "unpick" it, but develops
it for the Scottish context. The HTBS Comment highlights Scottish
contextual differences such as the epidemiology of illness/disease,
service structure in Scotland, principles of NHSScotland and other
issues such as remoteness. The process requires close and intensive
collaboration of HTBS and NICE staff, so that the HTBS Comment
is delivered to Scotland within six to 10 weeks of the NICE publication.
The HTBS Board has been extremely grateful to all NICE staff for
their cooperation in this process.
4.3 HTBS values the NICE "Information
for Patients" and uses it as the basis for its Guide for
patients and carers in Scotland relating to HTBS Comments. HTBS
is currently reconfiguring this Guide for patients and carers
to make it accessible as a general overview of the rationale for
the advice. This reflects HTBS understanding that issues relevant
to individual patients are quite different from those affecting
efficient uses of healthcare resources for the public as a whole.
The work of the Citizen's Council will be important in this respect
and HTBS looks forward to seeing the outcome of the discussions
of this group.
5. ACTIVELY PROMOTING
5.1 Recent goals set for NICE require an
increase in appraisals above the current level of 30 per year.
Given the limited expertise that exists in the UK (and indeed
the world) for undertaking the technical appraisal work and for
implementing the appraisal guidance in the NHS, one could question
whether this is an appropriate goal.
5.2 There has been concern that the scope
of some of the NICE appraisals is too limited and that a broader
scope may lead to faster implementation. Consequently, instead
of increasing the number of appraisals an alternative would be
to consider fewer, broader appraisals. HTBS undertakes such broader
assessments that address detailed issues of implementation and
early signs suggest that these are gaining professional buy-in
in NHSScotland (and the NHS).
5.3 Recommendation: The Committee
may wish to consider whether it is appropriate to ask NICE to
increase their capacity beyond 30 appraisals a year, or whether
Health Authorities may not benefit from fewer broader appraisals.
5.4 Recommendation: As it is now
mandatory for Health Authorities to fund interventions recommended
by NICE, the process for selection topics for NICE appraisal should
take cognisance of the theory around priority setting so that
implications for topics not considered by NICE can be considered
(both those of high value and those that may be disinvested locally).