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Using evidence to inform healthcare policy and practice: an overview of NICE. Kalipso Chalkidou, MD, PhD NICE International . UK NHS is free, largely, at the point of delivery and all residents are covered First (1948) and argest single payer publicly funded system in the world
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Kalipso Chalkidou, MD, PhD
First (1948) and argest single payer publicly funded system in the world
Annual budget of £100 billion
Not perfect; universal coverage with fixed resources involves compromises…but it provides a good level of cover
Private insurance in the UK approx. 10% and shrinking – privately insured continue to contribute to NHS through general taxation
"Subject to and in accordance with such directions as the Secretary of State may give, the Institute shall perform:
such functions in connection with the promotion of clinical excellence, and the effective use of available resources in the health service"
Article 3 (functions of the Institute) of the principal Order (March 2005)
HAS, July 2007
Developing NICE guidance
Patient and public involvement
Public Health Excellence
- public health interventions
- public health programmes
- clinical guidelines
Drugs, medical devices, diagnostics
Care pathways for whole diseases and conditions
Regulating new surgical techniques
Sentinel indicators of good practice: regulation and P4P
Costing tools and commissioning guides
Single technology appraisal process
84% of our advice recommends use…
342 individual recommendations in 160 technology appraisals
Review of Evidence
Academic group: university or professional associationOur Decision Making Process
PATIENTS AND CONSUMERS
SOCIAL VALUE JUDGEMENTS
NHS; PUBLIC SECTOR
Probability of rejection
Rituximab for follicular lymphoma
Imatinib for chronic myeloid leukaemia
Trastuzumab for early stage HER-2 positive breast cancer
Cost per QALY (£’000)
4 parliamentary enquiries: broadly supportive
“We conclude that NICE does a vital job in difficult circumstances. The development of more and more health technologies and procedures, alongside rising patient expectations and the ageing population, is going to make it even more difficult in the future. Healthcare budgets in England, as in other countries, are limited. Patients cannot expect to receive every possible treatment. NICE requires the backing of the Government. NICE must not be left to fight a lone battle to support cost- and clinical effectiveness in the NHS.”
Perceptions of NICE
Sources 1: Department of Health 2006/07; 2: DH 2005/06; 3: King’s Fund 2006/07; NICE 2006/07
Self assessment results – NHS Trusts
Source: The Healthcare Commission: Annual Health Check
"NICE may prove to be one of Britain's greatest cultural exports, along with Shakespeare, Newtonian Physics, the Beatles, Harry Potter and the Teletubbies"
The Triumph of NICE
Richard Smith, Editor BMJ July 2004
When NICE first started to flex its muscles in 1999, the drugs industry would love to have exported it, preferably somewhere like Mars.
Ten years later, the influence of NICE, far from being blunted, is beginning to spread. Its methods and organisational model have become something of a beacon to governments wrestling with the issues of efficacy and fairness in healthcare delivery.”
NICE goes global
Nigel Hawkes BMJ January 2009
Less than 3% of the global market
25% of global market uses UK prices in reference pricing
NICE website receives 400,000 unique visitors every month -50% from North America
Model of comparative effectiveness agency currently discussed in the US
Top health officials in Austria, Brazil, Colombia and Thailand said in interviews that NICE now strongly influences their policies.
“All the middle-income countries — in Eastern Europe, Central and South America, the Middle East and all over Asia — are aware of NICE and are thinking about setting up something similar,” said Dr. Andreas Seiter, a senior health specialist at the World Bank.
Not so different after all…
expectations and the promise of universal coverage and a guaranteed package
Finite budgets, low % public spending and resulting inequities of access
Policy and practice
Growth in health technologies – expanding global market
Andrew Witty [CEO, GSK] has also signalled his willingness to negotiate on price, in a climate where value for money is increasingly discussed and other countries are contemplating setting up a version of Nice
[The Bank] has, since 2007, been building up its activities in the less glamorous but equally vital area of “health systems”. This means getting local bureaucracies to recruit the right staff and deliver the right drugs to the right people at the right times, and knocking the heads of aid agencies together to eliminate gaps and overlaps in coverage.
“The UK’s National Institute for Health and Clinical Excellence (NICE) has established guidelines for the management of most clinical diseases and these have been used by many countries to determine how to allocate resources. The challenge is to adapt the NICE guidelines to the situation and medical practice in the country.”
“Disease burden estimations…cost-effectiveness studies of interventions…independent evaluations of programme implementation are examples of the kind of work that needs to be undertaken. In the absence of such capacity, current policy-making is ad hoc and driven by individual perceptions.”