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NICE Podcasts

10th anniversary podcast

Chief Executive Andrew Dillon speaks with BMJ editor Fiona Godlee about a decade of challenges and achievement and plans for the future.

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This podcast was added on 28 Apr 2009

Podcast transcript

Interview: Andrew Dillon

[music]

Announcer: You're listening to a podcast from the BMJ.

Fiona Godlee: Hello, I'm Fiona Godlee, editor of the BMJ, and I'm very pleased that we have Andrew Dillon with us who is the chief executive of NICE. NICE is ten years old in a couple of weeks Andrew, I think, so thanks for joining us.

Andrew Dillon: In April.

FG: So thanks for joining us. Really one might celebrate NICE's sheer survival given the public and overall pressures you are under. Are you confident that NICE is independent? I mean we had the Herceptin issue a while ago. Can you tell us your views on that?

AD: I can certainly answer the first question and the answer is yes, we are independent. But we are not divorced or somehow completely insulated from the fact that what we we do on behalf of everybody who uses the NHS in different ways. The way we go about our work and the way in which we formulate our recommendations has to be seen by those who use the NHS to be broadly correct. Of course it is very difficult to achieve that because there is a very human contradiction when you talk to people in the NHS about what they expect from it. On the one hand they expect the money available to be used efficiently and fairly. It's a great, very strong sense of social solidarity in this country. People think that the money that's available for the publicly-funded health system should be spread to the greatest benefit. But at the same time they are not very happy about costs being taken into account when individual treatment decisions are being taken. Now clearly you can't have one without the other. And NICE occupies that rather challenging space at the heart of that contradiction. So we have to maintain our independence - our independence of thought and process. But what we can't do is to divorce ourselves from the assumptions we make about the general expectations of those on whose behalf we are working.

FG: So what do you do, in future, if a politician were to put pressure on you to make a certain decision?

AD: Well they can put all the pressure they want but it won't influence the decision because whatever pressure they might want to bring to bear on me or others who work fulltime at NICE or on the board, that pressure can't be transferred through to our independent advisory committee.

FG: So the decision to approve Herceptin, you are saying, was not a result of political pressure.

AD: No it wasn't. Not at all. There was a lot of politics involved in the use of Herceptin before it was licensed let alone before NICE guidance came out. And everyone at NICE and those who were on the relevant advisory committee were certainly conscious of it. But nobody from the Department of Health - including the secretary of state at the time - came to us and said you must say yes to the use of Herceptin for early stage breast cancer. That was a judgement the advisory committee came to independently. It represented their genuine collective view about the right way to use that new indication.

FG: Ok. And what do you think is the right level of patient lobbying? There are concerns that the patient groups are in some cases 'spokesgroups' for the pharmaceutical industry. Do you have concerns about that?

AD: I'd be surprised if any patient group regarded itself as a spokesperson - 'spokesbody' - for the pharmaceutical industry. Some of them clearly do and freely admit to accepting funding from the pharmaceutical and other elements of the healthcare industry to enable them to do the job that they do. And I think as long as they make that clear, that's fine. And we are perfectly happy to engage with patient advocate groups at a national level - very interested to know what they think. However much we might think that it's almost inevitable that they are going to be advocating strongly for anything new, anything that has the potential to benefit the community that they serve, that is, it seems to me, entirely what they should be doing. But there is nothing wrong with starting from a position in which you believe that that is the right approach to take. What we do at NICE is to create a managed space for engagement where everybody who has got something to say about the work that we do can come and say it, and it can be heard by everybody else who may hold different views. And then it's the sometimes exquisitely difficult job of the advisory committee to reconcile all that opinion - and sometimes very expert opinion - with the evidence base that will have been assembled for them, either independently in some circumstances or directly from the manufacturing more rapid single technology appraisal process but nevertheless bench tested by an independent academic group before it goes to the committee.

FG: And I'll come on to the single technology appraisal process in a minute. Just picking up on the patient lobbying side, there is the alternative argument: not that patient lobbying is too intense but that the NICE process can't currently take into account enough of the patient's view, and in particular people with a specific condition under consideration, and that the NICE approach is very much to look at population values rather than patient experience in relation to a treatment. What is your view on that?

AD: Well it takes us back to that contradiction that I was referring to earlier that NICE sits at the heart of. We have to know what it is that patients with a particular disease or condition value in the things that are available to them to ameliorate their condition. Everybody would like a cure. Everybody would like to be restored to perfect health. But to the extent that in the vast majority of cases interventions don't do that, we need to understand what it is particularly that patients want. And when we have something new and there is some experience of it elsewhere in the world or already in this country through trials or other use, the views of people who are living with a disease or condition or those who speak for them is actually very important. The individual stories that come with that, although they bring to life the reality of what it's like to live with a disease or condition, are not of themselves arguments which can be taken into account. They are not the telling, differentiating argument in deciding whether or not to use something. We have to act on behalf of everybody who uses the NHS and we have to be aware of the fact that when we recommend the use of something that draws resources from the NHS that those resources are not going to be available for other things that people will equally expect the NHS to do.

FG: So you use this thing called the EuroQol five-dimension questionnaire - have I got that right? - for assessing those patient values in terms of each condition. And one of the criticisms is that doesn't take into account a whole load of aspects of what it is to have a condition or what a treatment might do for a patient in terms of ameliorating it.

AD: Although it's not perfect, it's actually a lot better than people sometimes present it as. And it's not static either. Those who are responsible for developing it are entirely conscious that it is a dynamic metric that needs to continue to be recalibrated against the expectations of those who consume healthcare. And they continue to do that. It's probably the best instrument that is available. The clinical studies that we look at don't always employ it, so we are not always even that far along in getting an understanding of the impact - as patients perceive it - on their quality of life of the interventions that we are looking at.

FG: Ok. We have in this week's BMJ an editorial which discusses this point about single technology assessments and how if a drug company does not provide you with any evidence, that your default is to make no recommendation, which is really allowing PCTs to go ahead an make use of the drug. And the editorial is raising the problem that that could provide a perverse incentive to industry not to provide evidence in some cases in the hope that you won't make a recommendation and the drug will be made available by default. What is your view on that?

AD: Well it has been in place for a while now. The evidence so far is that it doesn't seem to have stimulated companies choosing that deliberately as a route to avoid a judgement from NICE. And of course when we do reach a point where we have to terminate an appraisal - we say we are not in a position to recommend a treatment - we do that because we thought it would be wrong to say 'we are confident' to the NHS that we shouldn't be using this. Because we haven't had the opportunity to look at the evidence, in a sense it wouldn't be right to do that. But actually saying to the NHS 'we are not able to recommend the use of the treatment because' - and we give an explanation - sometimes, in one circumstance for example, the company themselves took the view they were unlikely to be able to persuade a NICE advisory committee the product was cost-effective. Well that's a pretty clear signal to PCTs that they should be at the very least very cautious about giving blanket approval for the use of that product in those circumstances.

FG: Because Scotland uses a rather different approach. I gather that they would say the drug should not be made available in the absence of other evidence. Is that right?

AD: I'm not absolutely sure actually, but let's assume they do. Fine. If they feel confident that the right thing to do is to in effect deny access to a treatment the evidence for which they have not seen, then that is a judgement that they need to make. And if the Scottish health system feels that is the right approach, then that's fine. But when we talked it through inside NICE, when we talked it through at our public board meetings to get this policy fixed, the judgement that we made was that although it's frustrating, it's disappointing, it's sometimes puzzling why companies might not find themselves in a position to provide us with the data, the fact is they haven't provided us with the data. So to give a clear signal that it is the wrong thing to do to use the product didn't seem to be right. To give a clear signal to the NHS that they should be extremely cautious about using the treatment in those circumstances did feel to be like the right thing to do.

FG: can we talk about the vexed issue of expensive cancer drugs at the end of life. Now NICE has effectively - I won't say thrown out - but extended its cost-effectiveness range in terms of QUALYs for these drugs. Can you give us a quick background to the thinking behind this?

AD: Well the most important thing to say is we certainly haven't thrown out the approach we take to calibrating our judgements, or for our advisory committees in calibrating their judgements, about cost-effectiveness. We still think that as things stand at the moment - although this can change as evidence that is relevant to it becomes available or the debate moves on and influences us to shift it - that broadly up to about £20,000 the NHS is probably doing the right thing to say yes unless there is some very strong reason why that is not right in an individual case. And between £20,000 and £30,000 it is getting riskier in terms of value for money but it's perfectly acceptable for the committees to support the use of treatments and they do on a regular basis. And above £30,000 committees need to have a pretty good reason. There must be something about the disease or condition, something about what is currently available, some feature or features of the intervention which the committee believes collectively mounts an argument for accepting a less cost-effective or high incremental cost-effectiveness ratio for that product. But when we looked at our methods document to see what we had written, there are about three lines that referred to how the committee might exercise its discretion when the ice [?] is above £30,000 per QUALY. And given the fact that two things: one is that we ourselves have gone through a pretty stormy period - and were going last year through a pretty stormy period - with new interventions coming in, many of which were expensive, many of which were being introduced right at the end of life with all the emotion surrounding them, and not unconnected with that Mike Richards had been asked to do a review by Alan Johnson of the circumstances in which it might be right or it might not be right for people to be allowed to use their own money to top up treatments particularly when NICE was saying no or saying only a partial yes, that we ought to look at that to see two things really: whether or not we had given enough advice to our advisory committees to enable them to exercise their discretion, and also whether or not actually the committees were, in every case, by referencing their conventional approach to using QUALYs for treatments that are at the high cost end, particularly for treatments that were being developed for small populations and especially and particularly - because this is what this new bit of advice is about for treatments that are being introduced to patients at the end of their lives with the intention of extending life - whether in those cases actually the standard application of the reference case as we call it - this framework for the consideration of the cost-effectiveness of a treatment - was actually in every case fit for purpose. And we were becoming a bit concerned that although QUALYs give advisory committees the ability to look at both improvements in the quality of life and extension to life, we were a bit concerned that they may not always capture all the benefits that the community as a whole associates with the capacity the NHS has in certain circumstances to extend life. It is very particular. So of all the things the NHS might do to improve mobility, to reduce pain, to improve our cognitive ability - everything that the health service does - all those things are highly valued. But the ability to extend life is something rather separate, we believe, and we can see this by going back over ten years of engagement with patients and the public, by looking at the work of our citizens' council. And we weren't entirely sure in every case that the way our committees were operating and the application of the standard approach to these things -

FG: Took account of that.

AD: Took account of that. So what we wanted to do was to say we don't think you are doing anything wrong. The committees were not, in some sense, deliberately trying to undervalue treatments that are designed to extend life. They weren't making mistakes in the application of the current methodology. What they were doing was being appropriately cautious in circumstances where a combination of features were, in some circumstances, putting committees in difficult positions where they felt that perhaps it was the right thing to do, almost at a moral level, to support the use of intervention, but that almost every other indicator that they were looking at in the appraisal pointed in the other direction. What we wanted to do was to make sure they were exercising their full flexibility, and that is what this bit of extra method - this bit of extra advice about how to exercise their discretion - was intended to do.

FG: Now if these expensive drugs are a great deal more used, it obviously has big implications for NHS budgets. But just before I get on to that, James Raftery in another article in this week's BMJ makes the point that these new rules for the expensive cancer drugs won't actually affect their availability very much because they all will fall down on this criteria of there being no other available treatment with similar benefits. What is your view on that?

AD: We need to wait and see because our advisory committees have already started applying the new rules. They did that at the beginning of January and there have been three meetings where at all three meetings - as it happens coincidentally - the rules at least have the potential to be applied, and we need to see when the documents from those committees start migrating to the public domain what effect it has had. What James did was to look back. It was an entirely sensible and logical analysis to look back to see, well, would this have made a difference had it been around for the last - I don't know, I think he looked at about 40 appraisals.

FG: And he found six, didn't he, where he feels that it won't make much difference to the availability?

AD: Yes. He doesn't feel overall that it's there. If you extrapolate what has happened over the last 40 or so forward, it doesn't look as if it would make much difference. What we did actually was to look forward at what is on the waiting list, what is in process, and we felt that there probably would be two or three a year where, looking at our forward programme over the next few years or so and averaging it out, there is at least the potential for it being useful as an aid for the committee in making their decisions. What the rate is going to be and how that rate of application converts in to positive decisions as opposed to the committee saying, well, even using this extra bit of process, it doesn't look as if we should be supporting a treatment in whole or part, just remains to be seen.

FG: Ok. NICE's threshold for Quality Adjusted Life Years - the £20,000 or £30,000 - hasn't changed since NICE was established. Should it?

AD: Well that is a question that we are going to address in about a week's time actually. There is a workshop coming up on Monday of next week - the 2nd February. Lots of people are invited to that: people who have got something to say because of the job they do, the particular expertise they have, people who have expressed an opinion about this both ways. There are people that say that even at £20,000 - £30,000 NICE is too generous and overburdens the health system. Decisions that are derived through that framework crowd out other interventions that are more cost-effective, it is alleged. And there are others who suggest that it has simply just fallen behind the pace and the risk is that really effective treatments that ought to be made available are simply not getting through. So arguments both sides of it.

FG: And where do your guts tell you it's going to fall? Is it NICE's decision or is this a political decision that is made elsewhere?

AD: Yes, at the moment. Nobody directs NICE to calibrate its judgements about cost-effectiveness. That's something that was left to us. All sorts of people have suggested that it ought to be done independently. It sounds at the moment it is still with us.

FG: And have you been through such a review before in the ten years?

AD: Yes, every three years we go through a pretty comprehensive review of our methods and processes and we invite views. In fact we go out to public consultation. And these arguments, both sides - it's too generous or it's not generous enough - both have been played out through the ten years we've had this debate which is why actually it has stayed where it is. But if it is clear that actually there is a different range, some different numbers that are clearly based on some logical analysis that is broadly supported by those who have got responsibility for funding, for providing health services, then that's fine and we are happy to change.

FG: So that debate is played out, funnily enough, in this week's BMJ. We have Adrian Towse arguing that actually, yes, we are slipping behind countries with similar per capita health spend on the one hand, and we have James Raftery really saying that unless we go low, unless NICE stops being so generous, fixed budgets are going to be blown because, for example, these expensive cancer drugs, but also just the sheer number of drugs that are being approved will blow the budget. So one of the issues - or the two issues that I think come out most interestingly are around opportunity cost and disinvestment and displacement. So on disinvestment, what should NICE be doing to help the NHS stop doing things that are less cost-effective than the interventions NICE is currently approving?

AD: We should certainly carry on doing what we have been doing because the less well known - certainly in the general public domain - clinical guidelines programme, which has now produced about 80 clinical guidelines, regularly feature recommendations for different approaches to interventions that are available. And so much so that for the last two years we've had a sort of 'greatest hits' of things not to do published on a monthly basis and we write out to PCTs and to our general circulation list saying that we have gone through this particular clinical guideline and here are some things. Just check. See what is happening locally. See if these things are going on. Take a look at why they might be going on. Take a look at the evidence that supported our recommendation for not doing, not using this intervention or using it in this particular way. And there may well be opportunities for releasing resources currently spent so that you can apply them on more effective things that either you decide locally or that NICE has recommended. We also, a couple of years ago, did a number of systematic trawls to try and find interventions where there was a prima facie case for either dispensing with them completely or using them fundamentally. We use the Cochrane database quite extensively. In fact we continue to look at it on a regular basis. And what we haven't found are masses of really useless things that for some strange reason the NHS is using at a very high level.

FG: Which suggests that there is some form of at least evidence-based logic going on behind the scenes even if not explicitly.

AD: Yes, I think collective individually, of course, clinicians are bound to only want to use those things that they have convinced themselves are really going to make a difference, and collectively I think the UK health system has been quite good at dispensing with stuff that just doesn't work.

FG: So what about this question of displacement, which is the sense that as NICE approves more drugs or more interventions, cost-effective things - things that are maybe as cost-effective or even more cost-effective than the things NICE is approving - are just going to get displaced because the budgets can't fund them. What can you do about that?

AD: Well I have enjoyed almost 34 years now of the happy task of squaring the circle of NHS budgets mostly through that period in operational settings as chief executive - certainly latterly during that period. So I understand the concerns that people have about the impact of the decisions made by well-meaning national bodies on the really difficult day-to-day business of making sure resources are allocated fairly. But the reality is that if NICE suddenly disappeared it's not going to stop all these decisions having to be taken. The healthcare industry will continue to innovate. All these products will come forward. There will be the same pressure from health professionals, from patients, to use these new products. These decisions don't go away. So better, it seems to me, to have an approach at a national level at least for those indications where some national evaluation is seen to be valuable and take a consistent approach to it, than in effect for the NHS to fracture into a hundred different little NHS systems around the place.

FG: Well that is what has happened, isn't it, that there is this pushing down away from the centre of the decision-making in some areas? And the sense is the PCTs will have to be making some of these disinvestment and displacement decisions, if you like. But we know from recent evidence and over a while now that PCTs don't really have the skills or the information to make those kinds of difficult decisions. So how could NICE or how should the medical community in general be helping PCTs to do their job more effectively in terms of allocation of resources?

AD: This sort of connects these two points that we've been talking about. One thing that I think is important - although I can blithely say that these decisions should be taken anyway and NICE is clearly the best-placed agency to fix on the right judgement in every case - which I know sounds rather arrogant although I believe it to be true - what we need to do is to make sure that we do that in a way that is seen to be reasonable, not just by all these patient groups and the industry around about, but actually very much by the NHS. So the two things that are going to happen over the next few months or so - one is the workshop on thresholds that we were talking about a moment or so ago - will very much have an NHS perspective. So the people who act as the brokers between our individual and collective aspirations for what the NHS should do for us and the reality of what our government makes available to the NHS from time to time, it's the people right in the middle of that sandwich at a local level who have to make all that work. The way we operate has to chime broadly with them. I mean there will always be people who will think we are not quite getting it right and will take a different view of it. But we've got to chime with the majority view in the NHS. So that workshop is important. And another thing that we are doing, which is related to it, is to launch a series of - well actually a study that is going to be chaired by Ian Kennedy who did the Bristol enquiry and who recently, until the end of March, chairs the healthcare commission - so somebody who is not directly involved in the world NICE has occupied but somebody who is very knowledgeable about it to chair an independent study which will include a series of workshops but will invite evidence on how NICE should go about valuing innovation, because this is often at the heart of the concern that people express locally. We always have to do the new thing. We are not doing enough of the things that we have already got and your decisions on new stuff, NICE, keep making it more difficult for us to build a basic array of services or do the other things that are never as glamorous as the things that you look at. And I'm very sensitive to that, not least because of the things I used to do in the NHS, the world, that part of the NHS that I've come from. So those workshops will very much involve people from the NHS because we need to make sure that what we do is consistent with the expectations of the NHS, just as it has to somehow try to be consistent with the expectations of the country as a whole.

FG: NICE may be judged in a number of ways, but one clear sign of its success seems to be that governments around the world are beating a path to your door to get your advice on how they might set up NICE-like models in their own countries. Nigel Hawkes has written a feature on this in this week's BMJ. He says that there are few other systems like the NHS, which might limit the applicability of the NICE model elsewhere. What is your feeling about that?

AD: Yes, I think he is right, if I'm understanding correctly what you might be saying, because I don't think you can take NICE in its current form and plunk it down anywhere in the world. It has grown as a sort of oddity out of the oddity of the NHS, if you see what I mean, in comparison with the rest of the world. It works where it works because it is plugged in to the NHS and the way the NHS functions. But what is clearly of interest around the world is the way we go about doing what we do. The methods and the processes, the approach we take particularly to transparency intrigues health systems around the world where these difficult decisions, where they are taken at all consciously, are quite often taken very privately and not necessarily terribly well represented to the communities that ultimately they effect. And I just think that transparency allied to what is self-evidently, though inevitably imperfectly, a really good quality analysis that is done well. It's based on methods which are tested and which are reviewed and which are subject to challenge. That actually works anywhere. It doesn't really matter how the health system is funded. It doesn't matter whether your aspiration necessarily is to provide a universal health system or whether you are acting on behalf of a defined community, everybody wants to get the most out of the resources that are available and particularly now, as money is so tight and the opportunities for growth are reducing everywhere around the world, it's just very important to make the money go as far as possible. People see in NICE a set of mechanisms and a set of approaches that allow that to happen. What we do you can apply elsewhere. You have to take the product and say 'we've done all this analysis and therefore, NHS, we should do this'. You can stop at the 'we've done all this analysis' and it gets you, whoever you are, to the point at which you can make a judgement about the optimal use of an intervention. Actually what is interesting is the optimal use of an intervention can be legitimately different in different parts of the world. It depends on what you expect. It depends on how much you are prepared to pay and expectations of consumers, the culture of clinical practice, the relative wealth of the health system all have an influence on ultimately what that judgement of optimal use is.

FG: No one would doubt that NICE has succeeded in getting cost-effectiveness and cost generally on to the agenda centrally in health policy in the UK. I was yesterday at the launch of the NHS carbon reduction strategy and someone asked whether NICE had a role in the carbon economy. As you may know, 60% of carbon cost in the NHS comes from procurement and half of that I think comes from the drug industry. The view was you have done jolly well on money and is carbon one step too far? What do you think?

AD: I think it's an intriguing proposition actually.

FG: Could you set standards for example in terms of the carbon economy for the drug industry?

AD: Well I don't know that we set standards of any kind for the drug industry, but I think if it was about helping the NHS to operate - and that would include what it bought as well as how it goes about the business of using its physical estate and how staff work and so on - it seems to me that the methods and processes and methods of operation that we put in place can probably lend themselves to it. Where there is evidence of any kind, I think the way we go about interrogating it and sharing the opportunity to interpret it works quite well.

FG: So it could quite possibly be applied.

AD: Yes, it sounds really good actually. I'm quite intrigued by the possibility of that.

FG: Great. I wonder if it would make NICE's job easier if politicians were more explicit about the need to ration. It's something that politicians, I think, find hard to state boldly but it's obviously a fact of healthcare. Could they help you in that - being more explicit?

AD: I think what would have been really good when NICE was launched - and NICE as much as the government of the day shares the responsibility to the extent that this might have happened and might have improved things - it would have been good to have had maybe a more broadly based presentation of why NICE was being created. There was certainly publicity at the time, largely directed into the NHS. It was very important the health service understood what NICE was about. That was good and it was done well. But I think maybe we could have, if we had thought about it, tried to sustain some dialogue in some way through the media, with the public generally, to say that the reason we set up this organisation was not going to make life worse, to create problems, to deny people opportunity for treatment, but actually to help us all make the best use of resources. Sometimes in doing that the decisions will be and seem very difficult for individual patients and groups of patients and these are the reasons why. I often find that when I'm presenting the difficult, the negative decisions as they are seen in the media, I'm sort of having to explain why NICE is there in the first place as context each time.

FG: Do you think it might be too late to make that case, or is it now implicit in what you do?

AD: Well I think it's the latter. Over the years the public sort of understand the fact that there is a health system and people need to make decisions in it. And there is this organisation called NICE and this is what it does. I think actually it is pretty difficult to get, on a case by case basis, people to accept that, when on the one hand they seem to be told there is something that works and is great and is the next wonder drug, that there is this organisation saying we shouldn't use it. Trying to find the time and the space and the language to unpick that and explain why that apparent contradiction isn't anywhere near as simple as it looks is pretty difficult. So I think what we'd quite like to do is to over time - and it will take time - explain to people, go back to what we might have done in 1999 to try to explain to people the contribution that NICE makes broadly and try to get across that those occasions where we say no - or where we are optimising the use of a treatment that there is any serious material restriction on what is right that people should get - are pretty rare, and try and advertise all the things that we do, all of which help to just nudge the health service along to providing a better quality of service and to do that more consistently.

FG: Transparency and accountability are pretty central to what NICE does and how it has survived in these difficult times. But it has been criticised for being insufficiently transparent, in particular in relation to the decision over Aricept. Could you tell us where we are on Aricept and why, in your view, there are limits to transparency for NICE?

AD: I don't want to be too critical about those who have challenged us on this and actually if people don't think we are being transparent then they should say so.

FG: But they have said so, haven't they? They've said specifically that the cost-effectiveness analysis that you have used has not been open to criticism.

AD: In this particular case yes they have and they went to court. And that is right and right in the sense that sometimes - although hopefully very rarely - the court is the right place to sort something out. But this issue is about whether or not - it's about versions of spreadsheets. I mean this is really angels dancing on the heads of pins, I think, when you step back and look at actually in the end what we needed to do in this particular case. And it all boils down to whether or not you get a spreadsheet that allows you to see the numbers and how the numbers work through to a particular conclusion, or whether or not you can change the numbers to do something else with them.

FG: And why not just share the spreadsheet?

AD: Well the line we took was that we think, as a public decision-making organisation, we should show our consultees what the advisory committee sees. So in other words, the people making the decision have a set of numbers to look at and they are making their decision on the basis of those numbers. It's right that we should show those same numbers to all the consultees so they can see it to and they can make comments on it. What didn't seem to make sense to us was we gave those numbers to our consultees and then they changed them and they gave another set of numbers back to the advisory committee. If they think there is a different set of calculations, if they think there is some other model that ought to be used, then they are free to build the model and to submit it. But the court decided it was right that they should get what is called an 'executable' version of the model. So it doesn't make any difference what I think on that anymore. That issue is resolved. We are going to be letting consultees have executable versions of the model in that particular appraisal and we have given an executable version out, and we've just, I think, come to the end of consultation on that and those comments will go back to the appraisal committee, and if they think that makes a difference to that recommendation they made on those drugs for treating Alzheimer's then they are free to do so. And in future all technology appraisals will give out that executable version.

FG: Almost everything that comes up for NICE seems to be something that will add to your workload. This seems to be a constant as the volume of appraisals you have to undertake and the methodology that is being constantly added to. Are you just going to explode under the pressure in terms of workload? How will you scale this up to the necessary level?

AD: We've been on a growth path pretty much for the whole of the ten years. We started off in 1999 with about £8 million and a single programme - a programme and a half because we were setting up our guidelines programme but we had a sort of technology appraisal programme. We're now about £32 million and we've got about five programmes. But we are going to go through a very rapid period of expansion, assuming the treasury has any money left to give us.

FG: So in ten year's time do you feel that NICE will look pretty much the same just bigger than it does today?

AD: Yes, I think it will. I think it will be delivering variants on what we are doing at the moment, better inevitably because we have improved over time, more of what we are doing. We'll have built and be operating by then what will be the world's best reference for NHS evidence, and we'll have consolidated the new things that are coming through this year and the QAF indicators around quality standards. I've no doubt that there will be other new things that will have come through for NICE. And we've got ten years of showing that we can do these things and we do it quite well. We're not perfect and some things that we've started off with - for example recently we've looked into whether we can make a contribution to patient safety but it looked like taking what NICE and the National Patient Safety Agency do together, it's best to let the NPSA get on and do that so that's fine. So there will always be things that come and go. Broadly speaking we've shown that we're competent as an organisation to take new things and deliver them successfully.

FG: Now, Andrew, this is a pretty tough job you do and I know you are subject to vilification from all directions and I gather that patient groups have been known to call you 'nasty' not NICE and you have dying people apparently camping outside NICE's headquarters when certain drugs and topics are up for decision. How do you cope with this, the pressure? How do you keep going?

AD: You can't do what NICE does and expect people to be uncritical and you certainly can't do what we do and expect that all the human emotion associated with health, the delivery of healthcare and the decisions that have to be made for individual patients not to be exhibited in their full array. It's just the reality of making these sorts of decisions. So people who work at NICE, and certainly people like me who have to present in public what we do, entirely understand that. And again this is not arrogance, but I think it's the fact that we are confident that broadly speaking, subject to challenge and fixing things when they're not right, that actually what we do is as good as it gets in terms of decision making. So to the extent that the decisions have to be made, although sometimes they are terribly difficult to present and impossible, in some circumstances quite understandably, for people to accept, that we're not doing something that's wrong or that is being done badly. And that helps an awful lot in being able to get through what are sometimes very difficult individual conversations or media interviews.

FG: And if there was one thing you could do to change the world in which NICE operates, what would it be?

AD: Well I think it might be that opportunity - and I can't imagine how one would construct it given everything else that people want to talk about - to put the workload aside for a minute, put all the controversial decisions aside for a minute and just sit down and have that conversation with the public about what NICE is there for, get the chance to explain that there are hard decisions to be taken but that we do them in a way that makes it probably as good as it gets anywhere, but secondly to say look at all these other great things that we do that we often never hear about but actually probably, in your different ways, you are benefiting from because the health service picks up our recommendations. And if we could have one extra thing, I would love it if there was some way of signalling to the NHS - perhaps as we go forward with quality standards in the future - that adds a greater strength of the signal for implementation of our clinical guidelines and our public health programmes, because the technology appraisals - particularly the drug appraisals - are seen to be so important that they get a lot of force behind them in the system. And that's fine. That's good. But there is so much else that comes out that can make such a difference. It would be great if we could have a whole systems approach which really energised and supported the NHS in picking up those other programme outputs.

FG: Andrew Dillon, thank you very much indeed.

AD: Thank you.

[music]

Announcer: For more information about this programme and other BMJ group podcasts, please visit BMJ.com

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Accessibility | Cymraeg | Freedom of information | Vision Impaired | Contact Us | Glossary | Data protection | Copyright | Disclaimer | Terms and conditions

Copyright 2014 National Institute for Health and Care Excellence. All rights reserved.