2. I do not have to check the insurance details or ability of the patient to pay. No money or credit card details are exchanged. This speeds up my clinic and administrative time so that I can concentrate on the clinical problems of the patient. It decreases the costs of providing healthcare, with far fewer administrative staff than are employed in the U.S. I do not have to get clearance from any third party before organizing investigations or prescribing medications (with the exception of NICE guidelines, covered below).
3. I work with other rheumatologist colleagues and a multidisciplinary team to whom I can rapidly refer appropriate patients. We have developed pathways within the department based on national evidence-based guidelines and local consensus. This decreases variation in practice among colleagues, which can be wasteful of resources. This managed approach is likely to be intensified, with the current government keen to introduce commissioning of services, specifying what services should include and which outcomes should be measured and achieved. This strategy may improve the value of healthcare, emulating some of the managed healthcare systems in the U.S. Some models of commissioning may include a budget for biologics, encouraging rheumatologists to see inflammatory arthritis patients quickly, and make best use of short-term steroid therapy and combinations of conventional disease-modifying antirheumatic drugs (DMARDs) before considering the use of biologics. Decreasing the need for just a few patients to be treated with biologics could release resources to be invested in other important aspects of multidisciplinary care.
4. In 1999, the Labour-led government introduced the National Institute of Clinical Excellence, which has undergone a number of name changes since, but is still abbreviated to the acronym “NICE.” NICE was created to improve the quality of care through guidelines, and to decrease the variation in availability of drugs across the NHS, often referred to as “postcode prescribing.” NICE allows health ministers to distance themselves from difficult and unpopular decisions on access to medications by delegating responsibility to an independent body that could render decisions based on evidence and health economics. These decisions always create controversy, because health economics is not a pure science, and the answers that emerge from models depend on the quality of data and assumptions that are put into them. However, there are advantages of NICE technology appraisals, including:
- Acknowledging and accepting the existence of bias, its manifestations, and its effects;
- Leveling the playing field for all interventions and all diseases by using cost-effectiveness approaches;
- Providing legally binding access to eligible patients, enshrined in the NHS constitution;
- Use of transparent methodologies;
- Publication of all their considerations;
- Removing some of the decision making on eligibility for biologics from the individual clinician, thus decreasing variation in practice;
- Revisiting available evidence every three to four years, during which time it is incumbent on stakeholders to improve the evidence base if they want NICE to reach different conclusions; and
- Increasing flexibility to negotiate with drug companies over the price charged to the NHS to reflect the cost effectiveness of the drug.
The disadvantages of NICE are:
