Managing uncertainty within NICE technological appraisals: the nature and impact of the ‘social features’ of decision-making

Managing uncertainty within NICE technological appraisals: the nature and impact of the ‘social features’ of decision-making

The National Health Service faces significant challenges in trying to meet people’s health needs with very limited resources. While new drugs are made available which mean serious conditions can now be treated, spending money on these (sometimes expensive) products will mean that other services have to be sacrificed. NICE (the National Institute for Health and Clinical Excellence) seeks to ensure that the NHS’s limited resources are spent on drugs which are cost effective – good value. Such cost effectiveness decisions are especially important as the NHS seeks to function on increasingly constrained resources.

The cost-effectiveness decisions made by NICE, known as ‘technological appraisals’, would appear to be highly objective and rational. Data about the cost and typical impact of the drug are collected and a decision is duly reached. Under more detailed inspection however, things are not so straightforward. There appears to be much uncertainty throughout the decision-making process – for example in terms of: whether scientific assessments of the effectiveness of a drug are relevant in everyday clinical situations; what we consider ‘quality of life’ to really mean; or how we make decisions about a drug’s likely long term, wide-spread impact from relatively small amounts of data. Moreover, the committee members who must decide whether a drug is cost effective or not cannot be experts in every aspect of information which is presented to them. Hence, they must listen to the opinions of experts in various fields and make decisions as to how much they should heed their assessments. Some of the relevant information will also be provided by the drug manufacturer(s) or patient groups, these representatives may have other interests besides helping NICE make the most equitable decision.

This research explores the ways in which various people (N=40) involved in NICE appraisal decisions, not least committee members, deal with these multiple levels of uncertainty. The key objectives are to explore the different approaches used for dealing with uncertainty and the impact of these methods on decision outcomes. The research is follow three specific drugs through the technological appraisal process – analysing the various documents produced by NICE which relate to these appraisals, observing the way evidence is presented and discussed at ‘open’ and ‘closed’ sessions of committee meetings, and interviewing a range of key actors and committee members to better understand their attitudes, beliefs and actions. By comparing the data produced from these three sources – documents, observations, interviews – we aim to develop an understanding of how uncertainty is perceived, considered, presented and tackled within these drug appraisals. From an institutional point of view this would enable more robust decision-making and therefore a more efficient use of NHS resources. At an ethical level this knowledge would help refine appraisals to assure more equitable outcome.

The study is led by Professor Michael Calnan of SSPSSR and also includes a contribution from Dr Patrick Brown from the University of Amsterdam.

Funder/funding stream

Funder: ESRC
Funding: £48,679