Tuesday, 22 June 2010

NICE work if you can get it

NICE wants us to go on a diet. According to its press release, widely promoted this morning before the budget swamped everything else on the airwaves, its new guidelines on cardio-vascular disease prevention, if implemented, would save billions of pounds and tens of thousands lives each year. They want a complete ban on trans-fats, greater restrictions on advertising, changes to the Common Agricultural Policy paying farmers to cultivate "healthy" food (as opposed to Big Macs and cream buns, presumably, which we all know grow on trees), changes to planning rules to force people to walk more, more advertising campaigns, and much much else besides. They're not lacking in ambition.

There has been much predictable criticism of NICE's apparent desire to micromanage people's lives, its technocratic attachment to behaviour modification - as though we were lab rats rather than citizens - and its empire building. I'm more interested in the extraordinary mismatch between the figures presented in the press release (and, thus, recycled on newspaper websites and by the BBC) and the details of the report on which they're supposedly based.

According to the press release, CVD costs the economy £30 bn a year and 40,000 "eminently preventable" deaths. Presumably, then, implementing the proposals would save that money and those lives. Not so. For one thing, the costing analysis (pdf) states explicitly that the guidance "does not cover individuals who are diagnosed as being at high risk" - the very people, in fact, who are most likely to die or, failing that, need intensive hospital care. Rather, the guidance is focused entirely on intervention "at the population level" - modifying the food intake and behaviour of the majority who are at low-to-medium risk, who might possibly die early from CVD but who will probably live to a ripe old age with or without it. It is, thus, aimed at entirely the wrong target - or would be, if preventing the largest number of deaths were truly NICE's priority.

NICE deliberately omits the targeting of measures not just at high-risk individuals but also at high risk groups. The report acknowledges, for example, that "death rates from CVD are approximately 50% greater than average among south asian groups". This, however, is considered a "fixed factor" that cannot be reduced by lifestyle interventions or other public health programmes - a clearly absurd proposition. In fact, if the sums of money contemplated in the report were targeted exclusively at south asian men rather than at the population as a whole, the savings in terms of lives (and presumably NHS budget) might well be greater, and would certainly represent better value for money.

The detailed figures are fascinating.

According to the costing analysis, in an area of high CVD incidence the cost burden on the health service amounts, over a five year period, to £75.1 million per 200,000 people aged 40 and over. If NICE's proposals are implemented in full, however, this would be lower - not £75 million lower but just £420,000 lower. At the same time, the cost of implementing the scheme over a five year period would be £236,000. So we're talking of a total saving of £184,000 from a total of £75 million. Obviously a saving is still a saving - but once you factor in the increase cost of pensions and social care of those people who aren't dying prematurely it will disappear. I tried to find out what assumptions had been made about the increased costs of longer life expecancy. Amazingly, the figures were not there. That dimension has been overlooked entirely.

The savings in terms of lives are equally small - not the 40,000 annually proclaimed in the press release, but somewhere between 800 and 1500. In a PCT area experiencing 14,000 CVD "events" per 200,000 over a five year period, the analysis expects that there would be just 75 fewer "events". The divergence between the press release and the full report is easily explained: the former assumes a perfect world in which NICE's wishes are translated into reality, no-one eats any fatty food and everyone does whatever quantity of daily exercise the quango deems optimum. In the press release, any death that can be prevented, is prevented. No-one dies - at least not from a heart condition, at least not before the age of 79 (NICE's definition of "premature").

The detailed costing analysis, more realistically, suggests a 3% "compliance rate" for their various "interventions" over a five year period. But then the report, unlike the press release, isn't really intended for public consumption. It is aimed at "government, the NHS, local authorities, industry and all those whose actions influence the population’s cardiovascular health (that is, can help keep people’s hearts healthy and prevent strokes). This includes commissioners, managers and practitioners working in local authorities and the wider public, private, voluntary and community sectors."

The press release, by contrast, is no more than a propaganda exercise. Its main aim isn't to induce a docile population to eat their greens, however. Rather, it is to raise the profile of NICE. Its guidance is scarcely revolutionary or even surprising - we've heard most of it many times before - yet the statement boasts that "there is an urgent need for this guidance" which is "wide-ranging" and will produce "enormous health benefits". The quango is trying to make the case, not just for the measures it recommends, but for its own role in recommending them. NICE, after all, has competition.

This is made unintentionally plain in the following section, which I recommend to the attention of Treasury bean-counters looking for cuts:

Government policy in many areas influences CVD. The Choosing Health white paper (DH 2004) set priorities for action on nutrition, physical activity, obesity and tobacco control. It was supported by delivery plans on food, physical activity and tobacco control, including the provision of NHS Stop Smoking Services.

Since that time, a wide variety of policy documents have been published including:

- Active travel strategy (Department for Transport 2010)
- A smokefree future: a comprehensive tobacco control strategy for England (DH 2010)
- Be active be healthy. A plan for getting the nation moving (DH 2009a)
- Commissioning framework for health and well-being (DH 2007a)
- Delivering choosing health: making healthier choices easier (DH 2005a)
- Food 2030 (Department for Environment, Food and Rural Affairs 2010)
- Health challenge England – next steps for choosing health (DH 2006a)
- Health inequalities: progress and next steps (DH 2008b)
- Healthy weight, healthy lives: a cross-government strategy for England (DH 2008c)
- National stroke strategy (DH 2007b)
- NHS 2010 – 2015: from good to great. Preventative, people-centred, productive (DH 2009b)
- Our health, our care, our say (DH 2006b)
- Putting prevention first – vascular checks: risk assessment and management (DH 2008d)
- Tackling health inequalities – a programme for action (DH 2003)
- Tackling health inequalities: what works (DH 2005b)
- Tackling health inequalities: 2007 status report on the programme foraction (DH 2008a)
- The NHS in England: the operating framework for 2006/7 (DH 2006c)
- The NHS in England: the operating framework for 2008/9 (DH 2007c)
- Wanless report: securing good health for the whole population (Wanless 2004).

A long list, but probably not an exhaustive one.

Time for NICE to go on a diet, I think.