Clinical practice is to be far more directed than hitherto. The National Institute for Clinical Excellence, which is just beginning to show its teeth, will see to that. Through guidelines issued under its aegis and the decisions it makes on whether new medicines and other treatments should be paid for by the National Health Service, it is going to have a profound effect on the way that doctors and other health professionals in England and Wales go about their business. Equivalent machinery will have the same effect in Scotland.
Admittedly, health professionals will not have to follow slavishly the guidelines that are issued, and doctors will be able to prescribe such drugs as zanamivir (Relenza), despite the NICE's view of them, if they feel they can justify it. But all the pressures will be on them to conform and the vast majority can be expected to do so.
With the NICE having such a profound effect, it is vital that it and the procedures that it adopts are beyond reproach. Perhaps these should be subject to some form of independent scrutiny - in the same way that the NICE carries out its examinations - in view of their vital importance to the NHS in the new millennium.
One of the things that might be included in the scrutiny is the composition of the committees that are making the real decisions - the technology appraisal committee, which works at normal speed, and the committee or committees used for rapid appraisal. If the technology appraisal committee (PJ, October 2, p512) was strong on academics and short on coal-face practitioners, the committee that rapidly assessed zanamivir (see p622) was even more academically biased. Out of a committee of 15 members, 11 were professors. Half of the rest were NICE staff. There were no full-time primary care practitioners or patients' representatives.
The products being looked at by the NICE will already have had their safety and efficacy assessed by the Committee on Safety of Medicines. The questions for the NICE are really about affordability. In many respects the decisions are political. If we allow this treatment, will we be able to afford that treatment? Are committees loaded with academics the right people to be making these decisions on behalf of the nation? This issue should be appraised as a matter of urgency.
Meanwhile, in Scotland, where the NICE's writ does not run, there is as yet no official line. The Scottish Health Technology Assessment Centre, which will carry out the appraisal work, is not yet up and running.