The formation of a new Labour government in July, led by Sir Keir Starmer, with a majority of 174 seats, has inevitably led to comparisons with 1997, when Tony Blair entered number 10 with an equally large majority. The parlous state of the NHS was a key issue in both elections. 

Back then Frank Dobson, the Secretary of State for Health, rapidly announced a new approach to health care quality in the policy document, ‘The new NHS. Modern and Dependable’ [1]. Two new organisations were to lead on a renewed drive for nationwide quality, fairness and equity. The National Institute for Clinical Excellence (NICE) was formed on 1 April 1999 to give a strong lead on assessing clinical and cost-effectiveness, and developing guidance that would reach all parts of the health service. The other new organisation was the Commission for Health Improvement (precursor of the current Care Quality Commission) to monitor quality. 

To coincide with the 25 year anniversary of NICE, Routledge have published a new book ‘NICE at 25, a quarter century of evidence, values, and innovation in health’. Edited by Peter Littlejohns and Keith Syrett (the authors of this blog), this collection of essays, drawn from a broad range of disciplinary backgrounds, offer analysis of key issues which have informed NICE’s work, from the principles of health economics, to patient engagement, to the legal basis on which NICE operates. 

Importance of healthcare prioritisation 

The book identifies that central to the Institute’s success was the acceptance that treatment options within healthcare needed to be prioritised and early on the Institute announced a set of guiding principles for all its endeavours. These were to be based on the best available evidence; decision making was to be open and transparent and involve all stakeholders likely to be affected by the decision (including academics, health practitioners, managers, industry, patients and the public); draft guidance would be subject to open consultation, be appealable and regularly updated. In essence, this was the practical manifestation of an approach to health prioritisation coined ‘Accountability for Reasonableness’ by Harvard population ethicist Norman Daniels [2].

What separated NICE from nearly all other clinical guidance developers was that it was required to explicitly take into account the cost of interventions – it was to assess value for money

Peter Littlejohns, Emeritus Professor of Public Health, King’s College London and Keith Syrett, Professor of Health Law and Policy, University of Bristol

The core methodology adopted was cost-effective analysis advocated by Allan Williams [3], including the concept of the opportunity cost - reflecting the view you can only spend one health pound once.

A key reason for NICE’s longevity has been its willingness to listen to criticism of its methods and make adjustments. However, having so many stakeholders with often contradictory aims and objectives has required a careful juggling act. While this has been managed sensitively during much of its lifetime, there are rumblings that some stakeholder views, such as large actors in the healthcare industry, are now dominating methodological developments [4] and with successive government policy being to incentivise innovation, the Institute’s original aims of fairness and addressing inequalities are not featuring as prominently as they should [5]. This is tricky territory for the Institute to be in, as the public sector, especially healthcare, is full of examples where government has prioritised innovation (particularly information technology) where the results have at best been negligible and at worst catastrophic [6]. A key risk for any organisation which adapts in this manner is at what stage does it cease to be the organisation it was at the beginning?

Diagnosing the NHS and the future role of NICE

With the health service being considered “broken” by the new Secretary of State for Health and Social Care Wes Streeting [7], he has commissioned Lord Ara Darzi to undertake a review to “diagnose” key challenges and how they should be addressed [8]. This will be a rapid process with publication of the findings in the autumn. The Darzi review allows a new look at NICE and to propose how it should evolve over the next 25 years. 

Whatever the results, there will remain a need to prioritise reforms and the lessons learnt over the last 25 years should not be lost. As part of the ARC South London (and before that the CLAHRC) a range of research projects have highlighted how this can be achieved fairly. 

Involving patients and the public at every stage will be crucial [9]. Prioritising prevention - which is always considered important, but is never done - will be fundamental to ensuring a sustainable NHS and NICE needs to be encouraged to renew its public health credentials

Peter Littlejohns, Emeritus Professor of Public Health, King’s College London and Keith Syrett, Professor of Health Law and Policy, University of Bristol

This societal approach will require a new social contract between the government, professionals and the people to rebuild the trust that has been dissipated over the last decades [10].

About the authors

  • Peter Littlejohns, Emeritus Professor of Public Health, Centre for Implementation Science, King’s College London 
  • Keith Syrett, Professor of Health Law and Policy; Co-Director, Centre for Health, Law, and Society; Head, Law, Regulation and Governance Primary Unit, University of Bristol Law School

References

  1. The Department of Health. The new NHS modern and dependable. Presented to Parliament by the Secretary of State for Health by Command of Her Majesty, December 1997 Cm 3807 published by The Stationery Office as ISBN 0 10 138072 0
  2. Daniels A, Sabin JE  Accountability for reasonableness: an update. BMJ, 2008.337, a1850.
  3. Williams A.  Cost effectiveness is it ethical? J Med Ethics1992 Mar;18(1):7-11. doi: 10.1136/jme.18.1.7. 
  4. Michaels A J. Is NICE losing its standing as a trusted source of guidance? BMJ 2023; 383 doi: https://doi.org/10.1136/bmj.p2571
  5. Charlton V, Rid A. Innovation as a value in healthcare priority-setting: the UK experience. Social Justice Research 2019, 32, 208-238
  6. Syal R. Abandoned NHS IT system has cost £10bn so far Wed. Guardian, 18 Sep 2013. 
  7. Guardian staff. Wes Streeting says NHS is broken as he announces pay talks with junior doctor. Guardian, 6 Jul 2024. 
  8. Government press release. Independent investigation ordered into state of NHS. 11 July 2024.
  9. Creating sustainable health care systems: Agreeing social (societal) priorities through public participation. Peter Littlejohns, Katharina Kieslich, Albert Weale, Emma Tumility, Georgina Richardson, Tim Stokes, Robin Gauld, Paul Scuffham. Journal of Health Organisation and Management. 22 November 2018.
  10. Littlejohns P,  David j Hunter, Albert Weale, Jacqueline Johnson and Toslima Khatun. Making Health Public: a manifesto for a new social contract. 21 November 2023