Conflict of Interest in NICE, CLAHRCs and Other Independent Organisations

In a previous blog the CLAHRC WM Director hailed the creation of NICE as one of the crowning achievements of the previous Labour administration – up there with granting independence to the reserve bank. NICE epitomised enlightenment values by bringing a highly rationalist approach to bear on NHS procurement decisions. Interventions had first to be effective and, if effective, they had also to be a better buy than the (nominal) activities displaced within a fixed budget. However, that was before the 2008 crash. The government, desperate to kick-start the economy, became susceptible to arguments to make NICE more responsive to the needs of industry. Companies would produce their own models, ‘single technology reviews’, to be critiqued by the NICE ecosystem, rather than the other way around. NICE would support industrial innovation for devices through a separate system of External Assessment Centres.

The economy is generally conceptualised in terms of the demand for, and supply of, products and services. The economy can be strengthened on both sides – providing better information strengthens the demand side, while innovations to meet demand strengthens the supply side. Can one organisation really do both simultaneously? Not according to a recent BMJ article reporting ‘insiders’ concerns that the new minister with responsibility for NICE will have dual appointments across the Department of Business, Innovation and Skills, and the Department of Health.[1] According to the BMJ article the new minister, George Freeman, is aware of the potential risk and will take steps to mitigate it.

So how may NICE manage this putative conflict of interest, thereby preserving its currently colossal international reputation? Well, it so happens that CLAHRCs also have a responsibility to work with industry and applicants had to say how they would do so on the application form. Three separate “ways of working” can be distinguished in which an independent organisation (such as NICE or CLAHRCs) may contribute to the national wealth agenda:

  1. Strengthening the demand side of the health economy by evaluating cost-effectiveness of interventions – in the case of NICE there are particular clinical treatments, while in the case of CLAHRCs they are the services that support individual treatments.[2]
  2. At the supply side, by strengthening industry generally – the industry, as opposed to any particular industry. One way of doing this is by supplying knowledge and tools that might be helpful to commercial enterprises in a certain sector. For example, CLAHRC WM has developed methods for health economic evaluations at the design and development stages of a new technology.[3] [4] [5]
  3. At the supply side, by collaborating with a particular commercial organisation.

It is only in the third of these “ways of working” that the potential conflict arises. To manage the risk we propose that:

  1. The potential risk should be acknowledged, not ‘pushed under the carpet’, since it is based on extensive empirical evidence.[6] [7] [8] [9] [10]
  2. The “way of working” should be crystal clear for any project.
  3. There should be no overlap between personnel involved in supply or demand side evaluations of a particular product at any time in its life cycle.
  4. Ideally an organisation should not be involved in supply and demand side evaluation of a particular product at the same time (but this criterion may be difficult to meet in a large organisation, such as a university or NICE).

These ideas have been “road-tested” in a presentation to the NIHR Office for Clinical Research Infrastructure (NOCRI) and to the NIHR Biomedical Centres and new CLAHRC Directors, but we would welcome comments and feedback.

— Richard Lilford, CLAHRC WM Director

References:

  1. Cohen D. Insiders say NICE is being encouraged to be more favourable to industry. BMJ. 2014; 349: g6387.
  2. Lilford RJ, Chilton PJ, Hemming K, Girling AJ, Taylor CA, Barach P. Evaluating policy and service interventions: framework to guide selection and interpretation of study end points. BMJ. 2010; 341: c4413.
  3. Girling AJ, Lilford RJ, Young TP. Pricing of medical devices under coverage uncertainty – a modelling approach. Health Econ. 2012; 21(12): 1502-7.
  4. Girling A, Young T, Brown C, Lilford R. Early-Stage Valuation of Medical Devices: The Role of Developmental Uncertainty. Value Health. 2010. 13(5): 585-91.
  5. Vallejo-Torres L, Steuten L, Buxton M, Girling AJ, Lilford RJ, Young T. Integrating health economics modelling in the product development cycle of medical devices: a Bayesian approach. Int J Technol Assess Health Care. 2008; 24(4): 459-64.
  6. Ethical Standards in Health & Life Sciences Group. Guidance on collaboration between healthcare professionals and the pharmaceutical industry. [Online]. 2012.
  7. Fletcher SW. Continuing Education in the Health Professions: Improving Healthcare Through Lifelong Learning. Chairman’s Summary of the Conference. New York: Josiah Macy, Jr Foundation. 2008. pp. 13-23.
  8. Spurling GK, Mansfield PR, Montgomery BD, Lexchin J, Doust J, Othman N, Vitry AI. Information from Pharmaceutical Companies and the Quality, Quantity, and Cost of Physicians’ Prescribing: A Systematic Review. PLoS Med. 2010; 7(10): e1000352.
  9. Steuten L, Buxton M. Economic evaluation of healthcare safety: which attributes of safety do healthcare professionals consider most important in resource allocation decisions? Qual Saf Health Care. 2010; 19: 1-6.
  10. Wang AT, McCoy CP, Murad MH, Montori VM. Association between industry affiliation and position on cardiovascular risk with rosiglitazone: cross sectional systematic review. BMJ. 2010; 340: c1344.
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One thought on “Conflict of Interest in NICE, CLAHRCs and Other Independent Organisations”

  1. I am running a piece of work for Oxford BRC/U to explore how best to align our PPI mandate with that on wealth creation – with a focus on responding to what patients tell us they want re the latter. You can see more here: http://oxfordbrc.nihr.ac.uk/blog/back-to-business/

    Can you tell me more re “These ideas have been “road-tested” in a presentation to the NIHR Office for Clinical Research Infrastructure (NOCRI) and to the NIHR Biomedical Centres” as it would be very useful to know what was said and to whom?

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