AD: Provide objective, but above all independent (from the government) advice on optimal approaches to clinical and public health practice.
TL: We have great variability in treatment practices across the U.S. Was that a concern in the UK?
AD: Variability existed and still does, but to a lesser extent, in the British system too. All NHS services are delivered locally, and doctors make their own decisions about treatment options. In the 1990s, many professionals, patients, and the media were conscious that there were differences in the availability of treatments across the country. It was variability that was another incentive to set up an agency that would give a national determination or a reference for treatment.
TL: Has it worked?
AD: Certainly it has. There is less variation now that there is a national reference on optimal approaches to care.
TL: Must doctors follow your guidance in making decisions about their patients’ care?
AD: No, but they generally take our recommendations into account. There’s no legal requirement that they follow the guidance. And we can’t instruct them to do anything. All professionals want to do the right thing for their patients. In Britain, doctors and others know that when they commit resources for a patient’s treatment, the money comes out of a national fund to which everyone contributes and which benefits all UK citizens (and overseas visitors who rquire emergency care.) So they are conscious of the need to make the best of the money that is available. They know that our recommendations are designed to ensure that everyone gets the best deal out of the money the NHS has. They respect them and use them in that context.
TL: Then how do you get them to comply?
AD: We rely on the collective responsibility of everyone who works in the NHS to do the best with the resources that are available. Doctors are conscious there are limits on what the country can spend on health care. There’s a finite amount of money. If there’s no benefit from a treatment for some patients, doctors know that money should be spent where there is benefit. If money is not spent on things that don’t work, that means there’s more money to spend for other patients—or perhaps the same patient who needs treatments that will be more effective.
TL: What does the word rationing mean in this context?
AD: Rationing often brings to mind the austerity and hardship experienced by people in Britain during the Second World War, when everyone got the same amount of food or clothing regardless of need. NICE does not allocate a fixed amount of health care blindly. We look at what people need and what’s available to treat them. Then we help patients and those who care for them make their choices within the overall envelope of money available. We rarely say that something has so little value or is so expensive relative to what it offers that it’s not a good use of NHS resources.
TL: Do all health systems make choices?
AD: Yes. No country can afford to fund anything and everything every citizen might feel they should have. All countries place limits on what is made available. Governments do, employers do, insurers do too. Most countries make sure their citizens have choices. People in Britain can decide to use the NHS, or they can take out private insurance. But most people who have private insurance also use the NHS.
TL: For decades, Americans have heard that there are long waiting lists for procedures. But hasn’t that changed in recent years?
AD: The NHS used to have long waiting times for elective surgery. With recent investment, people can more or less choose when they have their care. You can see a family doctor for routine care within twenty-four hours, and most non-emergency hospital care can be organized within a matter of weeks. Of course, all emergency care is both completely free and available on demand.
TL: How has that changed?
AD: The NHS has received significant additional funding. It has increased from around 60 billion pounds to around 90 billion over the last seven years. It is also better organized and better equipped.
TL: How much private insurance is there?
AD: About 12 to 15 percent of the population has some private health insurance. The number is going down because waiting lists are being eliminated.
TL: In other words, your government realized there was a problem and corrected it, is that fair to say?
AD: Yes, the NHS needed more money to provide the standard of care that people see available in other countries. It needed to fix the waiting list problem, and it needed more professional staff.