Page last updated at 00:07 GMT, Monday, 16 February 2009

Talking NICE around the globe

Emma Wilkinson
Health reporter, BBC News online

Assorted pill packets

It is almost a decade since the National Institute for Health and Clinical Excellence (NICE) was set up to assess what treatments should be available on the NHS in England and Wales.

Glancing back over its history, NICE seems to have been almost constantly dogged by controversy - most notably over decisions to limit access to Alzheimer's drugs and cancer treatments.

Yet for all the criticisms and legal challenges levelled at the institute, many countries around the world are keen to follow the example of NICE.

In fact the institute is often seen as a "beacon" of good practice internationally, say experts.

Last year, NICE took advantage of this reputation and set up a not-for-profit consulting business, to advise countries on modifying NICE guidelines for their own use or setting up their own "institute".

International reach

Kalipso Chalkidou, director of international health policy consulting at NICE said they had been advising other health systems on an informal basis for years.

This included being involved in the overhaul of the Canadian health technology system in 2004 and contributing to improving quality in public hospitals in South Africa.

And from monitoring hits on the website it is clear there is a global interest in their recommendations.

"Brazil is an interesting example - they have a system where they look at NICE guidance and adapt it to their own setting," she says.

NICE
Set up in 1999
Designed to end "postcode lotteries"
Independent of government
Provides guidance for England and Wales

"They look at the guidance and budget implications and unit costs and make the adjustments.

"The Serbians have a similar thing," she adds.

Turkey, Colombia and Azerbaijan are among those considering setting up their own systems for assessing the cost-effectiveness of health interventions and drugs.

"In Colombia we met with ministers about a month ago," she says.

"Their constitution requires them to come up with a basic package to which all citizens are guaranteed access.

"But they have been asked to make things more transparent as some things are listed and some are not."

Dr Leonardo Cubillos, Colombia's national director of insurance said the NICE expertise had been of "high value" to the country because their systems were "clear and fair".

Limited resources

Whether in a state-funded service, such as the NHS, or an insurance-based health system, making sure limited resources are spent appropriately is a universal problem.

And the middle-income countries across Eastern Europe, Central and South America and the Middle East, are arguably under the most pressure.

Dr Andreas Seiter, a senior health specialist at the World Bank, said pharmaceutical costs in terms of new medicines are growing fastest in middle-income countries where drug companies invest heavily in promoting the latest treatment.

There is no single country where the question of what drugs you should spend your money on is not an important question
Dr Andreas Seiter, World Bank

"In those countries, the relative burden is higher - if a new cancer drug comes in that costs $5,000 per patient and you decide to include the drug, the impact on the overall budget is very large.

"For example in Romania, in the top ten most expensive drugs, six or seven are very new drugs for relatively rare diseases such as hepatitis C.

"That money is then missing for treating people with hypertension or diabetes."

Dr Seiter says the World Bank is considering sponsoring a collaboration between the ministry of health in Jordan and NICE.

"There is no single country where the question of what drugs you should spend your money on is not an important question."

Such decisions are made routinely but not always with "procedural rigour" and in some countries judgements are dominated by a small number of specialists who can be hard to argue against, he adds.

Costs

The UK was not the first to set up a system for evaluating new drugs - Australia began to look at it through the Pharmaceutical Benefits Scheme back in 1993.

Canada has the Common Drug Review, set up in 2002 to standardise decisions on use of new drugs.

Germany has recently set up a system and discussions are ongoing in France.

But one aspect that seems particular to NICE is the strong emphasis on "value for money".

A recent decision to reject drugs used to treat kidney cancer on the basis of cost, provoked intense public fury.

It prompted NICE to revisit the guidance and the Institute have now approved one of the drugs, taking into account new, more flexible rules on decisions over drugs used at the end of life.

NICE is seen as a beacon of good practice, and it is attracting an enormous amount of attention
Prof Alan Maynard
University of York

Dr Erik Nord, senior researcher at the Norwegian Institute of Public Health says the UK has focused particularly heavily on cost-effectiveness with other considerations taking a back seat.

In Norway, he says, severity of illness and realising people's potential for health are given a much greater weight.

Concerns for severity, benefit and cost are placed on an equal footing and weighed against each other.

"So a small benefit can be recommended in patients who had a severe illness," he says.

Protesters on access to kidney cancer drugs
Some of NICE's decisions have prompted a public outcry

Professor Alan Maynard, a leading health economist at the University of York says countries are "progressing at different speeds in different directions".

"But every country is facing similar challenges - there's a lot of demand coming through and you can't fund everything."

He says another criticism of NICE's approach is that its guidance is expensive to produce.

"Appraisals can often take two years and cost 250,000 - the Scottish Medicines Consortium does it all in six months and looks at all drugs."

But he adds: "NICE is seen as a beacon of good practice, and it is attracting an enormous amount of attention."

He says even insurance companies in the US are beginning to dip their toe in the water.

"Insurance companies have also got a problem because they're not good at controlling expenditure.

"If Obama comes along and says everybody is going to have insurance the question will be how can we fund that."



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