03 August 2017

Difficult choices Professor David Haslam, NICE chair

David Haslam talks about the principles that guide decisions at NICE in the face of difficult choices.

A “new wave of NHS postcode rationing” has recently swept across the news agenda. The British Medical Journal revealed there are increasing disparities in local NHS funding for some treatments considered routine.  This strikes at the very heart of a key NHS principle: fairness.

However, we should not despair. The challenges we now face echo those that confronted us when NICE was created in 1999. The original intent of NICE was to reduce the variation in availability and quality of NHS treatments or care across England – and this still underpins all of the work we do today.

NICE has continued to focus on the difficult questions around affordability and, over this time, a series of key principles have been developed at the core of all of our work.

Local healthcare organisations and their commissioners could benefit from looking at the approach NICE takes when faced with difficult choices – an approach that has been tried, tested and improved over 18 years. The broad set of principles are as follows.

Use the evidence – everything NICE recommends is backed up by the best available evidence on what works clinically and financially. If faced with a decision that feels like “common sense”, make sure it’s backed up. For instance, is obesity really a risk factor if you are denying surgery to someone, or is it just a prejudice?

Work with experts – all NICE guidance is developed by an independent committee of experts from across the health and social care landscape. The experts also include members of the public, which is vital for a well-rounded end result.

Involve the public – every committee at NICE includes at least two members of the public who could be patients, carers or other individuals with an interest in our guidance. This ensures that our work reflects the needs of those who will be affected by it.

Ensure genuine consultation – NICE’s consultation process allows individuals, patient groups, charities, the industry and others to comment on our recommendations before they are published as final. We have a formal appeal process for our technology appraisal guidance. We listen, and then we respond.

Be transparent – to be trusted, it’s essential to be transparent. At NICE we open as many meetings as possible to the public, including our board meetings held across the country. With a local audience, NICE chief executive Andrew Dillon and I are able to answer queries from the public. If the public feel like we’re hiding from them, we can’t expect them to trust us.

In times like these trust is absolutely critical, and the tough decisions have to generate that, or suspicion abounds. And, as the NHS keeps saying, we have to get it right the first time.


  • This is, as you say, not new. As DPH in Cambridge I was intimately involved in such decisions. The discourse today has not changed one iota, for example, in the consideration of payment for assisted reproduction. The issue is not what decision emerges - but how the decision is taken. It is the quality of the process that gives the decision legitimacy. The failure by politicians of all parties to confront the mismatch between resources and requirements of a modern health service is a national tragedy. The NHS can no longer be an entity that provides COMPREHENSIVE health care to all at the point of delivery. But it can be a system that ensures that no citizen goes without REASONABLE health care for reasons of lack of resources. Would changing the discourse from the one to the other help to preserve NHS values?

  • Whilst I support the principles described above, it does not allow for CCG financial strictures and governance which may require some rationing of clinical services. We cannot escape the issue of healthcare rationing and there needs to be a national debate about this and sustainable NHS funding. NICE have an important role in this debate but not the last word.

  • Thank you for your comments, David and Ron. We hope that NICE can help to support those people working within the sector to strengthen it, and those of us who need to access care from it.

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