Reducing Health Inequalities – NICE and the search for the evidence

Its worth having a look at the talk given by Professor Mike Kelly who was the Director of Public Health Excellence at the National Institute of Health Clinical Excellence (NICE).

This talk was given at the Public Health System Reform Summit organised by the Kings Fund last month. It provides a helpful insight into the strengths and weaknesses of our current approach to evidence based public health commissioning in England.

Mike is a superb communicator for NICE – and his description of the health inequalities challenge that we face and our failure to close the gap is well put.

From what I understand of his argument he is saying that we have the evidence – the problem is its effective implementation. I think he goes on to say that he believes that there needs to be further work (by NICE) to bring a greater degree of detail (he calls it granularity) so that the evidence can be used to drive the practice of particular professionals in particular circumstances. The example he gives relates to the different roles of people in primary care with regard to helping people stop smoking.

Now I am not going to critique “brief interventions” here – I will leave that for another time.

What I am concerned about is the way in which government places NICE evidence as a gold standard which should drive our approach to public health decision making  – particularly with regard to tackling health inequalities – I am not convinced that this is right.

First a bit of context – NICE occupies a unique position in the governments policy landscape. As Mike says in his talk – “Healthy Lives, Healthy People” the Governments Strategy for Public Health in England affirms that Public Health England will:

“Ensure that the National Institute for Health and Clinical Excellence (NICE) adds maximum value by providing authoritative, independent advice on the evidence of effectiveness and cost effectiveness for public health interventions, working to specific commissions from Public Health England.”

And in footnote 106 of the same document (bear with me these things are important) he reminds us that:

“The National Institute for Health and Clinical Excellence has developed a way to conduct cost impact and return on investment calculations to accompany its public health and social care guidance and quality standards. This could provide the basis for decision making and priority setting at a local level by GP consortia and local authorities, enabling effective commissioning by Directors of Public Health”

So what does all these mean? Well, these two paragraphs anoint NICE as the lead agency for providing evidence on cost effective commissioning on Public Health to the NHS and to Local Government.

None of this is a problem – so long as – first – the quality of NICE evidence is of a sufficient standard to “enable effective commissioning” and second – the “specific commissions” by Public Health England actually focus on the real causes of health inequality.

So first, is NICE evidence good enough to help us reduce health inequalities? I am not convinced. My concern stems from Kings Fund talk. A focus on granularity – on the detail. This approach is equivalent to trying to trying to reduce carbon emissions by getting everyone to tune their car in order to reduce fuel consumption. The evidence base for tuning is probably solid but it makes little difference in the long run – the real strategic commissioning decision in this example is much bigger its probably about – increasing cycling, walking, use of public transport etc.

The NICE tendency – to focus on very small measurable interventions is historical. Its where the organisation started – assessing the cost effectiveness of drug therapies and surgical interventions. These can of course be measured and evaluated in a much more controlled way.

The problem arises when the same approach is taken to interventions to reduce health inequalities at a population level. The NICE model drives us towards the small scale, away from populations and towards interventions that are led by clinicians – it drives a medical model of health – it may be the most cost effective clinical intervention that has been tested – but that is all it is. It is not necessarily the most effective intervention.

Here is a not so hypothetical example.

Money is tight – a Director of Public Health goes in to see their new Cabinet Lead for Health. The councillor says – “the government continues to cut our core funding and I therefore need to save £2m. Give me your advice I have two services which need funding – one is a smoking cessation service – who are working according to NICE guidelines. The second is a welfare rights service – all of whose clients have chronic mental health problems with a very high proportion experiencing problematic debt and fuel poverty. I can only invest in one service – where should I invest the £2m – which one will make the greatest impact on the health and well being of the most disadvantaged?”

What advice can NICE offer these two people? My concern is that if you rely on NICE guidance this pushes us to where the evidence base is more complete – the smoking cessation service – so we end up with an approach to public health commissioning that only funds services where there is a NICE approved evidence base – even if – like smoking cessation –  the services are not actually very effective or relevant if compared against services that people really really do rely on like welfare rights provision.

For example I cannot remember the last time I saw a queue of desperate people outside a smoking cessation service – something that is common place with welfare rights services.

So – I think that if NICE are to be a genuinely powerful force for good commissioning they need to do the following:

First – have a bit of humility – most commissioning decisions in public health rely more on the experience of DsPH, other professionals and Elected Members than they will on NICE guidance – there are too many variables and not enough researchers. Lets acknowledge this a bit more – it will actually empower stakeholders for NICE to be saying this loudly and clearly at the front of every bit of public health guidance it produces.

Second – it would help if NICE focussed a bit more on broader strategic commissioning issues and less on the micro – less granularity please and more broad messages to commissioners.

Third – NICE is meant to provide independent advice. This only has meaning if it offers (where appropriate) challenge, otherwise why be independent? NICE does this well when it comes to challenging government policy on medicines, it needs to use its powerful evidence base to challenge wider government policy with regard to its impact on health inequalities. So more engagement with government policy impact assessments would be good.

Fourth – NICE needs to set its own evidence agenda more – and be less reliant on commissions from Public Health England – this could be awkward for NICE because in my view it means a  move from the apparent scientificity of its work to a more political analysis of the causes of health inequalities – but lets face it when you are producing evidence on tackling health inequalities – it comes with the territory.

Finally – for all of us – it is really important to confidently stand back and assess NICE guidance – does it really help? What is the paradigm it is working in? Lets be less slavish about the evidence and more confident in our own expertise and experience.