Interview: David Haslam, NICE

Since the UK government passed the UK Health and Social Care Act in 2012, few NHS-related bodies in England have been safe.

Primary Care Trusts and Strategic Health Authorities are no more – replaced by the mix of Clinical Commissioning Groups (CCGs) and NHS England (formerly the NHS Commissioning Board) – while several groups, including NHS Diabetes and Kidney Care and the National Cancer Action Team, have been amalgamated into more wide-reaching bodies that are aiming to reshape the healthcare environment in England.

One body that has remained largely intact, however, is the National Institute for Health and Care Excellence (NICE) – the organisation that provides guidance to healthcare professionals (HCPs) on the best course of care and evaluates whether health technologies are an effective use of NHS resources.

Although it may have recently changed its name from the National Institute for Health and Clinical Excellence to the National Institute for Health and Care Excellence to reflect an expanded remit covering social care, its main responsibilities remain in place, reflecting well on the body's achievements since it was created in 1999.

Much of this credit must go to NICE's founding chairman Sir Michael Rawlins, whose 14-year tenure saw NICE become one the world's leading health technology assessment (HTA) bodies.

His replacement, Professor David Haslam, is more than capable of filling those shoes, however, boasting extensive and impressive experience in UK healthcare that includes 35 years as a GP and stints as president of both the British Medical Association (BMA) and the Royal College of General Practitioners (RCGP).

Ready for the challenge
Prof Haslam is no stranger to NICE either, having chaired its NHS evidence accreditation sub-committee and attended strategy meetings of the NICE board.

“I became hugely impressed with the organisation and fascinated by the challenges it posed,” he says, but he's under no illusions that taking over from Sir Michael will be an easy job, especially at a time of chaotic change in UK healthcare.

“There are challenges across the NHS, at the moment one being to ensure all the new organisations work together effectively,” says Prof Haslam. “NICE is facing its own changes too, but the Institute has been pretty a much a success story and can be a beacon of stability.”

NICE's most major change is an expanded remit to provide guidance to ensure quality standards of social care. This, in addition to its existing responsibilities in healthcare guidance, and it's a challenge Prof Haslam feels he is in a good standing to help lead.

“Most of my career was spent as a GP, and I think NICE's remit has become so broad that it probably does need a generalist to give an overview,” he says. “GPs are dealing with healthcare, social care and people's experience in hospital, public health and so on, which is pretty much NICE's remit.”

Move with the times
This expansion is a logical step, according to Prof Haslam, as the relationship between health and social care grows stronger due to the rise of chronic conditions and an increasingly aging population.

“If you were inventing a care system from scratch in a new country, nobody would dream of separating health and social care,” he says. “There's such a clear overlap between them.”

“At the moment we have this extraordinary situation where patients are kept in hospital a long time, inappropriately and expensively, because of a lack of social care facilities to discharge them to, and that doesn't make any sense at all.”

This set-up should also help the UK's health system cope better with the rise of co-morbidities, with Prof Haslan putting patients living with more than one health condition at the top of his agenda during his time as chair of NICE.

Noting that there are more patients with two or more long-term conditions than with one long-term condition, he says the UK's approach needs to evolve from addressing a single disease.

“If you're a patient with heart disease, diabetes, arthritis and depression, which is a very common combination, you can't just add together all the guidance for those, or you end up taking 60 pills a day and having no quality of life,” he says. “So we need to look carefully at what we're trying to achieve for patients like that.”

As for NICE's role in supporting this change, it's a matter of producing the right guidance for patients rather than conditions.

“I think we need to work out what guidance for patients with multiple health problems will look like and what quality looks like for patients with lots of problems,” he says. “It needs to address what they want, rather than just taking all those single conditions and putting them together.”

It's not a situation NICE can sort out by itself, however, and Prof Haslan is keen to reinforce the need for collaborations in the new NHS and its new bodies.

“It's absolutely vital that we have close working relationships and we each understand what the other one's role is and what we're trying to achieve,” he says. “I think this is a very new time and there's going to be a lot of work required to work out with absolute clarity how the health and social care system fits together.”

Mutual respect
Although the two groups have never quite seen eye-to-eye on every subject, the relationship between pharma and NICE is also crucial to deliver good care in the UK.

Referencing the industry's work in HIV and cancer, Prof Haslam comments: “I think the industry has a lot to offer.”

This notion of respect and awareness of where each other stands is one that is mirrored back.

“I've found in the meetings that I've had with senior members of the industry there is a real recognition that the work NICE does is needed, and NICE does it as well or better than anyone else,” he says. “I'm really keen to build on good relationships.”

There are still challenges to be overcome, however, says Prof Haslam, commenting: “Not everything we do will be met with favour.”

He adds: “In an ideal world, you wouldn't need an organisation like NICE, even though evidence is always going to be helpful, but when there's infinite demand and restrained resources you have to work out the best way to address these resources and every healthcare system in the world recognises this.”

Value-based pricing
At the top of the list of concerns for most industry figures in the UK is the planned introduction of value-based pricing (VBP) for new medicines, coming in 2014, when the drug reimbursement process will change to assess drugs in a way that takes into account a wider definition of value.

Little is known about what this will entail, however, although it has been confirmed that NICE will take primary responsibility for assessing medicines in this new VBP system. 

“Our initial response hasn't changed, which is that we absolutely support the general principle that the NHS should pay a price that reflects the additional therapeutic benefit of drugs,” says Prof Haslam.

“We also share the government's ambition to ensure the option exists for new licensed drugs to be offered to patients that can benefit from them provided the price is a fair reflection of value.”

The pharma industry, especially the ABPI, has been vocal in its concerns about the impact of the new system on market access for new drugs, but Prof Haslam is more confident in its benefits.

“Don't forget the majority of tech appraisal decisions are already positive. And I think our anticipation would be that the new arrangements will ensure even more medicines have a price that's a fair reflection on that value.”

Innovation and reward
Prof Haslam is also keenly aware of the effort and cost that goes into delivering innovation and the industry's demand for appropriate reward.

“I absolutely recognise the tremendous importance and potential for innovation, both for patients and for UK plc,” he says.

“They are both extraordinarily important and we have to get the balance right between affordability of the health service and the need to develop new products.”

“I am very aware that in many areas, we [NICE and the pharma industry] are after the same outcome, which is best possible care for the population. I know that has the potential to sound cheesy, but it's the truth.”

A new aspect that Prof Haslam has yet to face in his career is the international impact of the NICE.

His previous roles at the BMA and RCGP have been very much UK-focused, but he is now in charge of a body the decisions of which affect prices for medicines all across the world as a reference source.

“One of the things I've learnt since becoming chair is just how wide our reach is,” he says. “I guess this is because, with all modesty, we are a world-class organisation in the development of HTA methodology and our work is conducted with transparency and openness”.

It's unclear what the impact of VBP will have on this authority, but Prof Haslam says the influential way NICE carries out its work will not change.

“I expect our methodology to remain as transparent and open and clear and evidence-based as it always has been.”

Regarding the future, Prof Haslam is committed to building on Sir Michael's legacy and maintaining NICE's reputation in healthcare and building its social care standing to a similar level.

Technology will have an impact on this process, with Prof Haslam acknowledging: “Maybe the most exciting potential lies in IT in the way that this will impact on decision making by clinicians, support for clinicians through desktop systems and, in particular apps and information for patients.”

It's important this information is meaningful, however, and NICE will have a job to do in providing evidence-based content to the general population.

“I think what the public wants is that they can trust the information that is being used and I think NICE can have a major role there,” says Prof Haslam.