Elsevier

The Lancet

Volume 353, Issue 9158, 27 March 1999, Pages 1079-1082
The Lancet

Series
In pursuit of quality: the National Institute for Clinical Excellence

https://doi.org/10.1016/S0140-6736(99)02381-8Get rights and content

Summary

In the UK, as elsewhere in the world, there is abundant evidence of unacceptable inequalities and inefficiencies in health care. These failures are manifest in various ways including inappropriate variations in the uptake and use of health technologies of proven value, the too frequent failure to provide patients with optimum care for the treatment of common diseases, and the too ready adoption of health technologies with no established clinical benefits. Healthcare systems worldwide are therefore struggling to find ways to ensure that their health professionals are able to provide patients with the highest possible and affordable–standards of clinical care. The British government has committed itself to a programme of enhancing the quality of care given to National Health Service (NHS) patients. The new National Institute for Clnical Excellence (NICE) has been charge with providing NHS staff with clear and robust advice that will help them meet their own, and their patients', aspirations. The Institute's guidance will cover individual technologies as well as the management of a wide range of conditions. NICE will also advise on appropriate methods of clinical audit in those areas where it has provided guidance.

Section snippets

Background

There is abundant evidence that the clinical care we give our patients too often departs from best practice. The reasons for our failings—and, as a practising clinician, I readily include myself—are broadly four-fold. First, we sometimes adopt new health technologies into everyday clinical practice without adequate evidence of their clinical effectiveness or of their cost-effectiveness. Second, we are sometimes too slow to introduce new methods of practice even when they have been shown to be

Functions

NICE will have three broad functions:

  • Appraisal of new and existing health technologies.

  • Development of clinical guidelines.

  • Promotion of clinical audit and confidential inquiries.

The Institute's output—in the form of advice to health authorities, NHS Trusts, primary-care groups, and health professionals as a whole—will not be mandatory. There is an expectation, however, that its recommendations on technologies will be universally accepted. Its guidelines will cover most clinical

Appraisal

NICE will be expected to give advice on the clinical effectiveness and cost-effectiveness of both new and existing health technologies (including pharmaceuticals, devices, diagnostic tests, surgical procedures, and other interventions). As soon as the Institute is established, around 30 to 50 technologies a year will be selected (by the Department of Health) for appraisal by the Institute. The results will provide health professionals and health-service managers in health authorities, trusts,

Clinical guidelines

Clinical guidelines have been defined as “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances”.3 Clinical guidelines are neither cookbooks nor textbooks. But where there is evidence of variations in practice that affect patient outcomes, and a strong research base to support effective forms of management, clinical guidelines can help health professionals to provide the most appropriate care.

There is

Clinical audit

The Institute's guidance (from its Appraisal Reports and Clinical Guidelines) will be complemented by advice on simple methods of clinical audit that will enable clinicians, Trusts, health authorities, and primary-care groups to monitor their own performance. In turn, local clinical audits will help the Institute to revise, or improve on, the advice it gives. NICE will develop further the work of the National Centre for Clinical Audit, whose functions will be incorporated into the Institute.

The

Structure

NICE has been established as a Special Health Authority with a Board consisting of a chairman, seven non-executive members, and four executives. The backgrounds of the non-executives are intended to reflect both the scope and the geographical range (covering England and Wales) of the Institute's activities. The executives will include a chief executive, a clinical director, a director of communications, and a (part-time) finance director.

Although based in London, NICE will in many ways operate

Priorities

The past few months have been spent establishing the infrastructure for the new Institute. Now that the essential components are in place, the real work can begin. The Institute's highest priority must be to earn, and then retain, the confidence of health professionals, of patients and the public, of NHS managers, of the Government, and (ultimately) of parliament. To achieve this, NICE must meet four conditions:

  • (1)

    secure broad technical competence;

  • (2)

    establish effective dialogue with

Technical competence

It is axiomatic that the advice given by NICE to the NHS is robust, based on all the available evidence, timely, and relevant. NICE must ensure that there is transparency of its procedures and, in so far as is possible, that the evidence on which its advice is based is publicly available and accessible.

Nevertheless there will be difficulties. Even the most robust appraisals and clinical guidelines based on a rigorous and systematic review of all the relevant data must necessarily carry an

Dialogue

NICE will need to communicate with a range of organisations that includes the health professions, NHS managers, the health-care industry, and patients and their carers.

The health professions, both as individuals and as organisations, will have a central role in helping the Institute to disseminate advice of the highest quality. The support of NHS managers will be essential for ensuring that the Institute's advice is implemented. An effective partnership with the industries that produce health

Communications

Unless NICE can ensure that its advice is effectively communicated to the NHS, its staff, and its patients, the Institute's establishment will have been pointless. It is for this reason that the Institute will have, at Board level, a Director of Communications to develop a coherent strategy for ensuring that the NHS is fully aware of the Institute's output. Furthermore, the strategy must also ensure that communication is a two-way process; since health professionals and patients will have much

Value for money

NICE has been established neither to cut costs, nor to introduce rationing, but to help the NHS get value for money. Indeed, anyone who believes that NICE will reduce NHS expenditure is whistling in the wind. To ensure, for example, that hypertension in the community is recognised and adequately treated, will unquestionably increase the drugs' bill; and, in the short term, will increase NHS expenditure. In the longer term, however, it will decrease the NHS costs of caring for patients with

Conclusions

NICE is part (but only part) of the overall strategy for “clinical governance”. I am confident, given time, that it will be able to improve the quality of care that is given to patients in the NHS. To do so, though, it must engage the attention not only of its most obvious “stakeholders” but of all health professionals in the service. But do not expect too much too soon: NICE's first Appraisal Reports and Clinical Guidelines are unlikely to appear before the autumn, 1999.

Over the past few

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