Professor Michael Rawlins , chairman of the National Institute of Health and Clinical Excellence, tells Lucy Quinton about his role and why the institute is more relevant now than ever before
Professor Michael Rawlins, chairman of the National Institute of Health and Clinical Excellence (NICE), is something of a breath of fresh air.
Having been appointed as chairman by Frank Dobson at the institute's inception in April 1999, Prof Rawlins' role, save for sitting in the House of Commons, involves managing the board. Saying that, he points out that his role at NICE does not actually involve managing the institute, which is run by the chief executive, but rather consists of contributing to its strategy and development.
He also actively monitors progress from the board's perspective and acts as ambassador for the organisation both in Britain and overseas.
NICE, which now employs 250 people, is the independent organisation responsible for providing national guidance on the promotion of good health and the prevention and treatment of ill health. However, it has not always been a large organisation.
When NICE was first set up, it advertised for non-executive directors, and Prof Rawlins recalls one candidate asking if NICE would work and Dobson being sceptical, although he added it was "worth a bloody good try".
Prof Rawlins says that, since starting his role, the organisation has gone from strength to strength. "What we do has expanded considerably and we have many more responsibilities than we had when we started. I think there are many people now that are well versed in the technical processes and what to do. In the early days, I had to do more hand holding, while now, in some ways, I am more 'hands off' in terms of the day-to-day business," he says.
When the institute was first set up, it was only meant to help the NHS and not the private sector, but Prof Rawlins says he is happy to help the insurance market. "NICE is not directly involved in advising the insurance industry, but it does take up our advice particularly on interventional procedures."
Prof Rawlins believes that decisions made by NICE have become increasingly important for the health insurance industry. "When we say that something is not safe, then the experience is that the health insurance market takes considerable note of that." He points to an example of wisdom teeth, where NICE ruled not to remove healthy wisdom teeth just because they are growing sideways and only to remove them if they are diseased. "Within days most of the major insurers removed cover for wisdom teeth," he explains.
He also thinks NICE has become the benchmark for the minimum standards providers should offer. "In our guidelines we lay down what I would have thought would have been minimum standards for the NHS but also the insurance sector too. Providers may want to add to that and that's fine, but they should at least be providing the level of service that we think the NHS should provide," Prof Rawlins says.
Alongside his role as NICE chairman, Rawlins has also been chairman of the advisory council on the misuse of drugs since 1998, which is an advisory panel to the Home Office. It recommends whether things should be controlled under the Misuse of Drugs Act, the level of that control and how to reduce harm. "We have a prevention working group that advises on how to prevent children taking drugs and strategies on how to deal with people who are dependent on drugs," he says. Although there are only two scheduled meetings of this council a year, Prof Rawlins says there are an awful lot of other things that go on in addition to it.
Prof Rawlins was interestingly unaware that some private medical insurance (PMI) providers delay implementing drugs on their policies until NICE has made a ruling, and while he says it is flattering, he urges them to err on the side of caution because he does not think the PMI sector should just follow NICE's lead.
"Sometimes we don't give advice on these drugs straight after they come out on the market and there are all sorts of reasons for that – some of that is down to us and some of it is extraneous – and they may end up depriving people of things that they really ought to be providing," he says.
Licensing
That said, he does not believe insurers should just start to offer all sorts of drugs that are available. He acknowledges that some providers sanctioned the use of herceptin before it was approved by NICE and says NICE's problem with the drug was that it could not make a decision on it until it had been licensed. "I think giving unlicensed treatment is very unwise," he says. He adds that in the case of herceptin it was particularly unwise as the drug can cause heart failure in a number of cases and the frequency with which it causes heart failure was unclear.
Cost plays "a considerable" impact on whether to approve drugs or not, Prof Rawlins explains, adding it is going to be incredibly difficult over the next few years if the cost of drugs rises. There are currently about 60 drugs that NICE is considering for approval. "Many companies realise this too," he explains, adding that the global pharmaceutical market employs about one million people, which is set to rise over the coming years. "We will have to simplify the process of drug development. Pharmaceutical companies may not be able to continue making double digit profits. The companies themselves spend twice as much as they make in profit on marketing – so that is a big expenditure. Most companies accept that it can't go on like it is," he says.
While he admits that some companies will try and get away with it for as long as possible, he believes there will be a change within the next five years.
Ideally, Prof Rawlins would like to see the industry continue producing lots of new innovative drugs at a price everyone can afford. However, "this needs changes in the mindsets of lots of different people and it has to be global. It's no good Europe saying it will cut out some of the studies that it has made on licensing when America still wants them because, in essence, America still rules.
"With the regulatory authority there is a will to do something. The trouble is that it is also under pressure to increase the requirements. It's a perverse incentive because it means that you have to do more clinical trials, which are more expensive. We have to get a balance between this and safety," he says.
Prof Rawlins feels that NICE should work more closely with the PMI sector arguing NICE guidelines should be the minimum standards provided by PMI providers. He says: "It seems to me that if the healthcare commission is looking at private medical providers, it ought to look at them from the standpoint of NICE guidance."
He says working as NICE chairman has been the biggest challenge of his career and, while he hopes that in 20 years' time it will also be his biggest achievement, he admits it is hard to judge when in the thick of it. For a man who now collects his pension, he is far from keen to sit in his rocking chair and mull the hours away.
While he is set to hang up his boots as chairman of the advisory council next year and bow out from NICE in 2009, he has ambitions to write the history of NICE after that. "I've been very lucky," he concludes.
