http://bmj.com/cgi/content/full/324/7331/191/a

BMJ 2002;324:191 ( 26 January )
News roundup
Katherine Burke, London

Official efforts to reduce "postcode prescribing" could backfire, because health authorities are being made to fund certain treatments at the expense of others, a parliamentary inquiry has heard.

Medical and legal experts told the Commons health select committee last week that the National Institute for Clinical Excellence (NICE) could—contrary to its aims—make prescribing more inconsistent by skewing healthcare priorities.

Ike Iheanacho, representing the Drug and Therapeutics Bulletin, warned that cash strapped health authorities may have to downgrade care in important areas to channel money into interventions approved by NICE.

"Health authorities will have to cut their cloth to fit," said Mr Iheanacho, the journal’s deputy editor. "If the cost of implementing a whole batch of NICE guidance means they don’t have enough money left and if [they] all end up cutting different things, it’s hard to see how that will stop postcode prescribing."

NICE has been put in an "invidious position," because it was expected to prepare reams of guidance almost as soon as it was created, said Dr Martin Duerden, a part-time GP and medicines policy adviser at University College London Hospitals NHS Trust.

Dr Duerden told MPs that the resulting backlog, or "NICE blight," had caused delays in local healthcare decisions, and inconsistencies in the guidance had confused prescribers.

"[It’s] created many problems for healthcare organisations and they’re trying to hold back, till they get information [from NICE], before they can make strategic decisions," said Dr Duerden. "In many respects it’s worse than it was before."

He added that health authorities have to fund interventions within three months of NICE approving them, which can divert staff away from other projects with high local priority.

To ease the institute’s workload, Dr Duerden suggested hiving it off into separate bodies—such as a national cancer institute, a national guideline institute, and a national new drug advisory committee.

Experts also pointed out how NICE’s narrow focus on drugs and technology will indirectly skew health priorities through errors of omission. Christopher Newdick, reader in health law at Reading University, said that NICE has chosen not to consider other types of intervention, such as increasing the number of community nurses.

"That money will have to be taken away unless the [health authority’s] money increases each year sufficient to cover the cost of implementing guidance," he said.

The legal clout of NICE guidelines was questioned too. From 1 January health authorities were obliged to "normally" follow the institute’s guidelines, but this falls short of a government guarantee last July that health authorities will always follow the guidance.

"Given the promise that was made before Christmas ... I would certainly urge some clarification," Newdick advised the select committee. "Five years of NICE costs are going to be very significant and that will eat into the remainder of the [health authority’s] budget."

One solution, suggested by Professor Tom Walley from Liverpool University, was to ringfence funding for certain high volume drugs that an average GP would regularly prescribe. "NICE itself should get more funding so it can sit back and take a wider view of managing conditions," said Walley, a professor of clinical pharmacology.

Newdick suggested that NICE guidelines be given tiered status, so health authorities would be obliged to fund drugs that contribute to the modernisation programme but would have more discretion over other guidelines.

"We should trust health authorities to deal with their own local priorities," he said.

During the hearing NICE was also criticised for inconsistent advice and for failing to be open about its decision making process. Guidance on drugs for influenza, type 2 diabetes, attention deficit hyperactivity disorder, Alzheimer’s disease, motor neurone disease, and adult obesity all came under fire for inconsistencies and omissions. And patients’ organisations complained that they were not informed about how their evidence had been used, if at all, in drafting NICE guidance.