Editorial

Nature 461, 315-316 (17 September 2009) | doi:10.1038/461315b; Published online 16 September 2009

Taking the NICE path

See associated Correspondence: Gibson, Nature 461, 1198 (October 2009)

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The United States can learn from the UK body that rates the effectiveness of medical procedures.

In the highly polarized debate over US health-care reform, opponents of increased government involvement in the system frequently caricature Britain's National Health Service (NHS) as the disaster they want to avoid — an impenetrable snarl of red tape that keeps ailing pensioners on years-long waiting lists for even the most essential procedures. And at the heart of their nightmare is the UK National Institute for Health and Clinical Excellence (NICE), portrayed as a bunch of callous government bureaucrats ruling life-saving medications as off-limits to dying patients.

Globally, however, NICE is widely regarded as a world leader in comparative-effectiveness studies: research that aims to show which of the available medical options is most effective at treating any given condition, and which is worth the money — what US reform opponents might call 'health-care rationing'. Faced with an overwhelming yet incomplete medical literature, most medical professionals welcome NICE's best-practice guidelines on everything from early testing for breast cancer to child nutrition.

NICE's politically and emotionally fraught function can arouse intense feelings. In one example last year (see page 336), NICE had to make a Solomonic choice: should the NHS spend an extra £31,000 (US$51,000) per patient for a treatment that would give a few more months of life to victims of a terminal renal-cell cancer? Or should it spend that money on other potentially life-saving interventions such as breast-cancer screenings, or insulin for diabetics? NICE, following its established cost–benefit guidelines, opted for the latter — and immediately found itself the target of intense organized lobbying to reconsider, which it eventually felt compelled to do, and the institute modified the guidelines for some patients with short life expectancy.

NICE should be extremely cautious about going too far down this road: changes made under pressure from one vocal patient group can make it that much harder to draw the line for the next — and to maintain the agency's commitment to evidence-based decision-making.

However, NICE's decision-making process remains an honest and increasingly open effort to take empirical evidence about clinical effectiveness, and combine it with the value that the British public — not faceless bureaucrats — put on their health and their lives. The available methods for assessing that value do leave something to be desired. NICE asks people to rate various states of health on a numeric scale, for example — a standard technique in medical economics — even though it is hard to know whether such hypothetical assessments are meaningful to people who are facing death in reality. But there are efforts under way at NICE and by other health economists to improve on such methods. And the United States — where comparative-effectiveness research received a $1.1 billion boost from the economic stimulus earlier this year — should contribute to this effort.

Meanwhile, even as Americans — and many British citizens — view the UK health-care system with bemusement, the British look across the Atlantic Ocean with equal puzzlement and sometimes horror. They see Americans dying with cancer and losing their homes because they cannot afford treatments that are not covered by a health insurance plan. Millions of people cannot afford to go to a doctor at all.

That is the nightmare that the American politicians must urgently resolve, and they would do well to stop being afraid of NICE and start taking cost-saving lessons from it.


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