According to recent reports, NICE looks set ‘to lose its power to turn down new medicines for use on the NHS’. Instead, ‘groups of GPs will decide whether a drug should be funded or not’.
Put in these terms, one could see these reforms as part of a wider agenda geared towards greater localism and public empowerment. Of course, some commentators have raised worries about the risk of a new ‘postcode lottery’ in the NHS, as different GPs make different decisions about what to fund.
However, there is the sense that, whatever problems the reforms would create, they would still move funding decisions away from ‘Big Unaccountable National Institutions’ towards ‘Local, Approachable, Sympathetic People, Perhaps Like You or Me’. Hence, we may feel that, even if these changes have certain drawbacks at a national scale, at an individual level, they are in my best interests – at least, assuming my GP is particularly generous.
But is this really the case?
First, we need to be clear about what is actually being proposed. Certainly, one thing that the Government cannot be proposing is to take away NICE’s power ‘to turn down medicines for use on the NHS’. NICE never had, nor claimed to have, any such power.
On occasion, NICE has concluded that certain medical technologies are either ineffective or not cost-effective (although perhaps a lot less often than people may think – only 11 per cent of decisions by NICE did not recommend the use of a technology on the NHS).
However, NICE is only able to advise the NHS what not to fund, it does not have the power to ban rejected treatments.
So, for the announcement to make any sense, the Department of Health must be proposing not to take away NICE’s power to turn down medicines, but to dilute the force of its recommendations. For while NICE’s rejections may not have any real power over funding bodies, as the NHS Constitution spells out, the NHS is under a legal obligation to fund drugs and treatments NICE has recommended.
On this reading then, the new idea proposed by the Government is not ‘to let GPs decide’ whether or not to fund a drug NICE has rejected, but rather ‘to let GPs decide’ whether or not to fund a drug NICE has recommended.
If this is the case, we could still say that these reforms move decisions away from ‘Big Institutions’ and towards ‘People Like You and Me’. However, we may now be less sure that they are necessarily in our own interest.
Rather we have moved from a situation in which a NICE ‘yes’ means a local ‘yes’, and a NICE ‘no’ means a local ‘maybe’, to one where a NICE ‘yes’ and a NICE ‘no’ both mean a local ‘maybe’. In effect, we will have moved from a world where (at least some) technologies are guaranteed to be funded, to one where none are.
Let us say that, for whatever reason, we are still happy with these proposals. Perhaps we like the move from ‘Big Institutions’ to ‘People Like You and Me’ so much that we are willing to forgo a degree of certainty about which technologies are funded by the NHS. Even in this case, are we right to portray this reform as a move towards greater accountability?
Two things make this questionable: first, there is no guarantee that the new ‘groups of GPs’ will be as ‘Local, Approachable and Sympathetic’ as we may first think; second, NICE may not actually be the ‘Big Unaccountable Institution’ we sometimes see it as being.
It seems natural to suppose that ‘groups of GPs’ would be more accountable than a national institution such as NICE. We know we can contact our local GP relatively easily and voice any concerns we have, whereas national bodies often appear distant and foreboding.
However, we must not forget that, under current proposals, it is not our local GP that will be making the decisions NICE used to, but rather our local GP consortium. And it is entirely possible that our GP consortium will be just as distant as, say, PCTs are at present.
The White Paper suggests that some local accountability will be provided through the creation of local Health and Wellness Boards. However, these Boards are only described as having ‘influence’ over local commissioning decisions, not holding GP consortia to account.
Hence there is a danger that the only way patients will really be able to hold their local consortium to account will be through the civil courts, much as patients currently challenge PCTs over exceptional funding requests.
By contrast, NICE seems far more receptive to public concerns. It makes strenuous attempts not only to involve the public in its decisions but also to make its processes and decisions as transparent as possible.
Moreover, its size and status do have certain advantages. As a highly visible public body, NICE has an incentive to ensure that its decisions are as fair and equitable as possible, especially when weighing up the claims of different patients. Shrouded from public view and the gaze of the media, multiple smaller and less visible bodies are unlikely to have similar incentives.
The implications of reforming NICE, therefore, are much less clear cut than they may initially seem. As with many of the proposals set out in the White Paper, the devil will be in the detail.
Rumbold B (2010) ‘The proposed reforms to NICE: power to the people?’. Nuffield Trust comment, 14 December 2010. https://www.nuffieldtrust.org.uk/news-item/the-proposed-reforms-to-nice-power-to-the-people