The national institute for clinical excellence (Nice) has been ordered to advise the NHS on the best and most cost-effective ways to treat high-profile conditions including heart failure, eating disorders and diabetes.
The guidance was issued by health minister John Denham today as part of the government's attempts to tackle what it regards as unacceptable UK-wide variations in access to and the quality of NHS care in a number of key areas.
Nice will advise on the cost and clinical effectiveness of eight new health technologies, including drugs for arthritis, schizophrenia and people who want to give up smoking.
The institute will ultimately decide which new drugs and technologies are to be used by the NHS to treat these conditions. Its latest programme is expected to take at least a year to complete.
Nice has already issued guidance on 15 technology appraisals, including controverisal decisions to "ban" the flu drug relenza and fund taxanes cancer drugs.
The programme announced today is as follows:
Smoking cessation: The Nice appraisal will provide GPs with cost and clinical effectiveness evidence for the use of the smoking cessation aids NRT and bupropion (Zyban) in primary care. It will play a significant role in the government's aim of reducing cancer, heart disease and smoking rates in the population.
Schizophrenia: Last year, the Department of Health (DoH) commissioned the Royal College of Psychiatrists and the British Psychological Society to develop guidelines on the management of schizophrenia. Preliminary work was undertaken to look at the evidence concerning the so-called "new" anti-psychotic drugs. This made it clear that a thorough examination was needed of the evidence for all the drugs relevant in the management of schizophrenia, including the traditional drugs. Nice will ensure that a thorough, independent review of the evidence is carried out.
Rhesus disease: The DoH welcomed publication of the guidance on prevention of Rhesus disease from the Royal College of Obstetricians and Gynaecologists. This guidance included a new recommendation that routine antenatal prophylaxis - an injection of immunogobulin - should be offered to all Rhesus negative women in pregnancy to make a rare cause of neonatal deaths rarer still. Nice will advise on the clinical and cost effectiveness of this treatment as a routine prophylaxis.
Crohn's Disease: Crohn's disease is distressing for sufferers, and it is believed the numbers affected are growing. The Nice appraisal will look at the use of the drug Infliximab, in line with licensed indications, after conventional treatments have failed, and Nice will advise on extended and repeated use as well as single dose.
Rheumatoid arthritis: Rheumatoid arthritis affects about 5% of women and 2% of men. Nice has been asked to appraise two new treatments, Etanercept and Infliximab, which are used if anti-rheumatic drugs are no longer effective.
Asthma in older children: There is high use of asthma inhalers in childhood and considerable variation in treatment regimes and differences in the range of inhalers available. This increases the difficulty in providing a quality package of care, improving the control of asthma and lessening the effect on children who suffer from this common condition. A more considered and evidence based approach to the treatment of asthma in childhood is needed. Nice will consider and advise.
Asthma care: New evidence-based national guidelines are needed for the management of asthma in adults and children in both primary and secondary care. These will help reduce the number of asthma attacks. Current guidelines are not evidence-based.
Heart failure: Heart failure affects a growing number of people, particularly the elderly. It can be difficult to diagnose and the quality of treatment offered is extremely variable. Patients are subject to frequent acute hospital readmissions due to poor symptom control and often suffer a poor quality of life, particularly during the latter stages of their illness. These clinical guidelines will help doctors and other medical staff in both primary and secondary care deliver more effective diagnosis and treatment for these patients and improve their quality of life.
Eating disorders: Expertise and services are not equally distributed around the country. Not everyone who needs treatment is able to access it easily or quickly. These points are made in the national service framework for mental health. The guidelines will cover the full range of treatments normally available as part of healthcare for people judged to need help. Inpatient treatment is the "established" approach for severe cases of anorexia with extremely low body weight, but outpatient treatment is appropriate for less severe, more common cases and for people with bulimia. Treatment usually involves a form of psychological therapy and advice and guidance on nutrition. In young people, families are commonly involved in treatment as well.
Depression: Depression will affect nearly half of all women and a quarter of all men in the UK before the age of 70 and, at any one time, the prevalence of major depression in the general population is about 5%. Severe depression also carries a raised risk of death by suicide and this is now the second most common cause of death in those under the age of 35. Depression is a common condition, with the vast majority of cases managed in primary care, but services for people with depression are of variable quality, and services are sometimes difficult to access.
Caesarean section: The Government is concerned about the variation in caesarean section rates between hospitals and has a programme in hand to address this and the reasons for the rise in caesarean section rate overall. The national sentinel audit will establish the reasons behind caesarean sections. Nice will use information from this survey to produce evidence-based guidelines for when a caesarean section is necessary.
Common medical emergencies: The work will produce a series of guidelines covering a range of situations where immediate action needs to be taken either to deal with an acute emergency or to prevent an emergency taking place. They will be up-to-date and evidence based and will be continuously updated. Guidelines on healthcare associated infection Healthcare associated infection is a serious problem for the NHS. It can be life-threatening and uses considerable NHS resources. The guidelines will help promote sound infection control in both primary and community care. They will also provide clear statements of good practice for all staff.
Head injuries: Initial assessment, management and referral. The major concern in the management of head-injured patients is to detect damage and impairment early and minimise secondary brain and spinal cord injuries. Prompt and effective initial management can limit the number of patients left with significant behavioural, cognitive, emotional and physical disabilities. Development of clinical guidelines will support the implementation of the health secretary's priorities for modernisation strategies, in accident & emergency, care of critically ill adults, strategy on paediatric intensive care, caring for vulnerable people including children.
Diabetes: The management of type one diabetes has a significant impact on health, including the likelihood of developing long term complications. People with type one diabetes have a life expectancy 25% lower than people without diabetes. Yet there are marked variations around the country in current practice as well as in the outcomes of care. The development by Nice of clinical guidelines for type one diabetes will contribute to the implementation of the diabetes national service framework, which is to be published in 2001 for implementation in the NHS from 2002.
Under consideration for referral to Nice:
Ramipril for patients with heart disease: Recent trial evidence suggests that the drug Ramipril may significantly reduce the risk of death, heart attack and stroke for many patients with or at risk of heart disease, and in particular patients with diabetes. The appraisal by Nice of Ramipril will support consistent and effectively targeted prescribing of the drug for these patients.
Growth hormone replacement: Growth hormone has been used for many years to promote growth in childhood, essentially where there is an absence of naturally produced hormone. However this treatment has sometimes been used to promote growth where there is little evidence of benefit or hormonal deficiency. There is also a lack of sufficient information on the long term results of growth hormone treatment in children of short stature. The highly demanding nature and high costs of this treatment require an optimised prescription, and this remains to be determined. Nice will consider this. This appraisal will also be extended to adult use, subject to further consultation.
