NICE was established in an attempt to end the so-called postcode lottery of healthcare in England and Wales, where availability of treatments depended on the NHS Health Authority area in which the patient happened to live.

It was set up as the National Institute for Clinical Excellence in 1999. In 2013 NICE was renamed the National Institute for Health and Care Excellence reflecting its new additional responsibilities for social care, it is classified as an executive non-departmental public body (NDPB).

NICE publishes guidelines in four areas:

• the use of health technologies (such as the use of new and existing medicines, treatments, and procedures)
• clinical practice (guidance on the appropriate treatment and care of people with specific diseases and conditions)
• guidance for public sector workers on health promotion and ill-health avoidance
• guidance for social care services and users.

These appraisals are based primarily on evidence-based evaluations of efficacy, safety, and cost-effectiveness in various circumstances.

Since January 2005, the NHS in England and Wales has been legally obliged to provide funding for medicines and treatments recommended by NICE's technology appraisal board.

The process aims to be fully independent of government and lobbying power, basing decisions fully on clinical and cost-effectiveness.

NICE carries out assessments of the most appropriate treatment regimes for different diseases. This must take into account both desired medical outcomes (i.e., the best possible result for the patient) and also economic arguments regarding differing treatments.

NICE guidance supports the use of quality adjusted life years (QALY) as the primary outcome for quantifying the cost effectiveness. One QALY equates to one year in perfect health.

Currently one can roughly presume that following an appraisal if the cost of a QALY  is <£20,000 it will be approved. If over £30,000 it will be unlikely to be approved though this is not set in stone.

NICE has a service called Clinical Knowledge Summaries (CKS) which provides primary care practitioners with a readily accessible summary of the current evidence base and practical guidance.

Criticism of NICE and the whole process:

• Lots of areas not assessed.
• Too slow (New Cystic Fibrosis drug, injections for macular degeneration a major cause of blindness).
• Dispute over accuracy. (The publication of the nice guidelines for ME/CFS 2021 has caused controversy for content which is at odds with research evidence and the incorporation of wrong information)

In 2022 a study by Price Waterhouse Coopers (funded by the pharmaceutical industry) of 13 medicines recommended for asthma, kidney disease, stroke prevention and type 2 diabetes. They found that 1.2 million patients had not received the drugs which could have given them the equivalent of 429,000 extra years in “complete good health”

The new NICE guidance on Barrett’s oesophagus and stage 1 oesophageal adenocarcinoma: monitoring and management, is due to be published in February 2023. The consultation period ended on 5th October 2022. I sent comments along with Professor Fitzgerald and Heartburn Cancer UK.

Speaking purely for myself my comments related to a missed opportunity to discuss how we could diagnose more people with Barrett’s. At the moment only about 20% of people are diagnosed. GP guidance for dealing with heartburn is slightly vague, in my experience when working and trying to influence GP referrals they respond well to specific guidelines to follow and not to vague ones. I had hoped they would be more positive about Cytosponge’s role in case finding. They did acknowledge the current evidence was encouraging but really left it that more was needed.

BEST4 is a large study which should start in 2023 and I hope this will provide the cost-effective data that they need.

I hope the work part funded by HCUK with the mobile unit and piloting the use of Cytosponge in general practice will also continue and add to our knowledge of how to attract the right people to be screened in the real world and different sorts of practices.

NICE started looking at Barrett’s in Nov 2020, so you can see it is not fast. When it is published, they usually have a planned review date. I am hopeful at that time we will have the evidence they need.