One NICE is Enough
From the Frankfurter Allgemeine Zetiung
26 June 2003

By Stephen Pollard

There is a golden rule in public policy: the name of a body is, almost always, the exact opposite of its real effect on the world. The UK's National Institute for Clinical Excellence - known as NICE - is a typical example of this phenomenon. Hailed by the Labour government, which set it up in April 1999, as a means of promoting excellence across the National Health Service, its real effect - one might say its real purpose - has been rather different: to restrict the variety of treatments available to patients.

The parallels with the proposed new Center for Quality Medicine are uncanny. Its proponents argue, as did NICE's creators, that its concern will be to ensure that all Germans receive access to the best medicines. By examining the effectiveness of different treatments, the members of the Center for Quality Medicine will be able to issue guidance to doctors across all of Germany, ensuring up to date knowledge of the latest research and that the most effective medicines are used on patients.

It sounds wonderful in theory. But the practice, as NICE shows, is rather different. In reality these decisions are about not widening the range of treatments but narrowing them; not increasing the options but restricting them. They are, in short, designed to ration health care, and to do so in the most misleading manner possible - on the pretext of rationality.

The rationale behind such a policy is clear. The healthier we get, the more we spend on healthcare. Demand for healthcare seems to rise inexorably, driven by a cocktail of demographics, new technologies and expectations. Across the globe, those responsible for the delivery of healthcare strive to find ways to limit the rate of growth in spending. These have taken a variety of forms, from HMOs in the US to restructuring of some social insurance models. Whatever other merits they have, they all have this same overriding concern as a driving force.

When the Labour government set up NICE, the National Institute for Clinical Excellence in April 1999, it heralded it as a body by which excellence could be spread throughout the NHS. As one of its main decision-making tools, NICE employs economic evaluation, a method which is becoming increasingly required by healthcare decision-makers. Economic evaluation involves the comparison of the costs and consequences of alternative treatments for a given condition. It is promoted as a rational, scientific means of allocating resources and containing costs. In reality, it is a spurious justification for rationing drugs which would have a significant impact on spending.

The crucial words are 'clinical excellence', and how they are defined. The unavoidable truth, which will apply to the Center for Quality Medicine as much as it does to NICE, is that such decisions cannot be value-free. The decision making process - which drugs to allow, and which to bar, represent a set of value judgements which are hidden from view and may not reflect the values that the general public would like to use in the allocation of healthcare resources. Such decisions go to the heart of economics - and of politics. Indeed, the cynic's view of NICE is the only plausible view: the very purpose of basing rationing decisions on the outcomes of such evaluation is to provide a supposedly objective alibi behind which intensely unpopular political decisions -rationing healthcare - can be hidden. Subjective choices about which treatments to deny, and to which groups of patients, are thus disguised as objective decision-making, and given entirely spurious credibility, when in reality they are no more objective than any other political decision.

Even the most cursory look at NICE's methodology and purpose shows precisely how it ends up denying treatments to patients which they would otherwise have had. The list of drugs which NICE now refuses to sanctions is almost endless:

Last year NICE said that irinotecan and oxaliplatin should not be used as first line treatment for advanced colorectal cancer, even though they are licensed for this in the UK with an established drug 5FU. They added that a third drug, raltitrexed, should only be used in clinical trials. The real reason? The newer drugs cost £1,200 per patient a year, compared to the £70 of more traditional treatments.

Later in the year NICE said that there was 'insufficient evidence' to recommend the use of a new cancer medicine which has clearly proved its efficacy in the treatment of patients in two of the three phases of chronic myeloid leukaemia. The medicine has been licensed for all three phases in 65 countries around the world - but not, thanks to NICE, in the UK.

Relenza for influenza, beta interferon for multiple sclerosis, herceptin for breast cancer: on and on the list goes, all on the basis of supposed 'clinical excellence' - and all, in reality, based on a desire to save money.

If the Center for Quality Medicine is indeed established, Germany will end up with exactly the same deceptions, and the same problems. Do not be seduced by the rhetoric. The reality is not excellence, but rationing.

Stephen Pollard