Oxford Martin School: Making Decisions with NICE’s Sir Andrew Dillon

Sir Andrew Dillon, chief executive of the National Institute for Health and Care Excellence (NICE), visited Oxford University to discuss the diverse roles of NICE. He gave a detailed overview of the structure of NICE and its relationship with the NHS, as well as briefly commenting on some areas of criticisms focused on the institute.

NICE is a public body, formed in 1999, established with the aim of becoming a national point of reference for NHS workers and patients. It uses clinical evidence to promote the best therapies, judged on their cost-effectiveness, considering both health and social care policies. Dillon characterised NICE as the cool-headed, reasoned independent agent which allows NHS practitioners to make informed, practical therapy decisions.

 Dillon revealed the process by which NICE might come up with a guideline. He described this process as making sense of the “maelstrom of noise” surrounding the complex motivations and evidence behind the development of new therapies. Costing only about £65 million per year, the organisation is mostly staffed by part-time volunteers. NHS frontline clinicians meet at NICE to discuss new medical evidence and how this should affect their therapy advice. As new evidence is considered, new treatment guidelines are formed, taking into account the cost of therapies, and their expected results. Guidelines are systematically reviewed in the same way as new evidence emerges, aiming to keep NICE, and so, the NHS, up to date with the latest available therapies.

 Dillon highlighted the difficulty of deciding which therapies to promote, given the great cost they might present. The uptake of one therapy will take funds away from others, and so key to NICE’s work is making sure that the benefits of that therapy should outweigh the losses associated with those therapies which will lose out. Fundamental to NICE’s work is the appreciation of the finite resources available to the NHS.

 It is here that Dillon addressed some criticism facing NICE, surrounding its lack of endorsement of certain cancer drugs. He gave the example of a drug developed by Roche for metastatic cancer, which might allow a number of patients to avoid the often highly unpleasant chemotherapy. This drug currently costs around £160,000 per cycle, per patient. The evidence available for NICE was not sufficient to warrant such a huge price tag, given the diversion of NHS resources that uptake would necessitate. Dillon suggested that pharmaceutical companies should consider offering such impressive and expensive drugs at a lower price initially, so that NICE can endorse their prescription, and gain its own clinical evidence as a result. He has advocated such an approach publicly before, prompting significant discussion in newspapers such as The Guardian.

 Upon opening up the talk for questions, Dillon received a final barrage of criticism with regards to NICE’s recommendations for the treatment of type 1 diabetes by insulin pump therapy. An audience member pointed out that the UK has much lower uptake of this treatment than the USA and the rest of western Europe, and that the evidence for the benefits to patients of such therapy was strong and widespread. NICE, however, has very restrictive guidelines on the endorsement of this treatment. It is also the case that Clinical Commissioning Groups frequently ignore these restrictions, recognising the benefits of this therapy, which is in the long term, relatively inexpensive, and prescribing this treatment to patients who do not meet NICE’s guidelines. What then, is the point of NICE in these situations, the audience member asked, when its guidelines are out of step with the rest of the world, and ignored even by those who they are written for.

Dillon concluded the event by responding that NICE is not infallible. It makes mistakes, and must endeavour to update its guidelines as frequently as is useful. He ended by considering a quote by the MP Frank Dobson, when asked whether NICE might survive; “Probably not”, he said, “but it’s worth a bloody good try.”