Is it time to make NICE guidance mandatory?

I’ve seen a lot of comments on social media over the past two weeks saying that the NHS is trying to cost-contain its way out of the most challenging period in its 76-year history.

The financial reality at Integrated Care Board (ICB) level is dire. They’re being tasked with delivering financial balance against a backdrop of ever-rising workload and demand, which is an incredibly challenging ask.

Over the years, I have come to the view that you cannot cost-contain your way out of a situation like this. If the patients don’t get a good outcome, they simply come back and that costs more money.

The answer I’ve come up with might be controversial but it’s this – it’s time to make NICE guidance mandatory.

Patients who need care don’t get better by themselves

Let’s assume for a minute that Einstein was correct when he defined insanity as doing the same thing over and over again and expecting a different result.

So why are NHS commissioners trying to cost-contain and reduce overspending when we know that doesn’t work? When patients are unable to access care services, they don’t suddenly get better – in fact, the opposite is often the case; they relapse and have events that lead to more appointments, more referrals and more non-elective admissions to the hospital.

When beds are full of emergency patients, the NHS often ends up cancelling the planned appointments, planned care, planned surgery and planned diagnostics and the backlogs continue to grow.

General practice is delivering 20 per cent more activity than it was pre-pandemic. It’s doing in excess of one million appointments per day and we’ve got 3,000 fewer GPs than we had in 2016 – and that’s still not enough activity.

We also have emergency departments seeing around 74,000 patients per day (that was the figure for February 2024) – and that’s still not enough activity.

Prevention costs less than a hospital admission

So why don’t we make implementation of NICE guidance mandatory and try to prescribe our way out of the financial black hole?

My rationale for this is that we often have new treatments that go through the NICE technology appraisals and get approved. They tend to have low numbers needed to treat (NNT)—that’s a measure used in assessing the effectiveness of a treatment, the average number of patients who require treatment for one to benefit.

Many NNTs are in single figures – I’m working with one product right now where the NNT is four, so for every four patients you treat, you avoid one hospitalisation. But even that is viewed as too expensive.

I look at it in a different way.

The cost of the drug treatment is less than one per cent of the cost of a non-elective admission to hospital, which is more than £20,000.

Keep in mind that for every four people we treat, we keep one out of the hospital. So, how many patients can be treated with the £20,000 we’ve saved by keeping someone out of the hospital?

I’m also working on projects with two much lower-cost NICE-approved medicines, where the NNTs are as low as 19 and 21. Yet the NHS still hasn’t adopted these medicines as the primary products in those particular pathways – despite the cost of heart attack, stroke, or chronic kidney disease admission being vastly more expensive than the cost of treating people.

Gold standard treatment deteriorates over time

Imagine for a moment you’re in a leaking boat. Would you spend all your money on buckets to bail out the boat? This is, in effect, what’s happening now by not implementing NICE guidance with all the money going on funding non-elective hospital admissions.

Alternatively, you spend the money on repairing the boat (implementing NICE guidance) to avoid having to buy buckets. In NHS commissioning terms, invest in better medicines, implement NICE guidance, prevent or slow disease progression and reap the reward of patient outcomes leading to fewer appointments, referrals and non-elective admissions.

It’s starting to become a choice over what we invest in. Do we invest in prevention, or do we just let people be hospitalised? That leads me onto an area that I find in my work all the time: sub-optimal treatment.

Read my blog on connecting your sales pitch to the NHS’s prevention agenda by clicking here

No healthcare professional ever deliberately suboptimally treats a patient. Suboptimal treatment comes about over time, possibly two, three or more years where what was gold standard then is now deemed to be sub-optimal. Millions of patients are still on that treatment because in that gap of time newer, NICE-backed treatments have not been adopted.

Correcting it and delivering better outcomes would cut down the number of referrals, appointments and non-elective hospital admissions.

Suboptimal treatment is easy to correct

I was involved in a project in East Sussex involving hospital trusts, community services and general practice via one primary care network. The hospital consultants in three different disease areas kept a count of outpatient referral pathways for a month and highlighted that between 75 per cent and 80 per cent were there because they had suboptimal treatment.

I’ve subsequently seen the same story replicated in numerous projects, with the sub-optimal treatment usually breaking down into four categories:

1. The patient is correctly diagnosed but is on the wrong treatment. That’s often because they were started on a treatment but then – for whatever reason – they’ve stopped taking the treatment and have ended up in outpatients.

2. The patient is correctly diagnosed but is on an old treatment. They will be on the previous gold standard treatment and now find themselves suboptimally treated and in outpatients.

3. The patient is correctly diagnosed and on the right treatment but is on the wrong dose. Where they’ve been initiated onto treatment but have never had their dose titrated.

4. The patient has never been diagnosed. Where the diagnosis happens in the outpatient department.

All we’re talking about here is medicine change. What was the patient on when they arrived in outpatients? Their treatment is optimised, what are they on now? Going through that process eradicates the suboptimal treatment.

Projects like this convert into a two-cycle CQC audit for general practice, a major benefit to the companies running the project and the general practice delivering it. All practices have to deliver a minimum of 3 x two-cycle CQC audits in 12 months so this is a huge added value at practice level and it doesn’t change the project.

If work is focused on improving patient outcomes, then ultimately, appointments, referrals, and non-elective admissions will be reduced. In my work, reducing workload is the absolute holy grail so it’s a very good angle to work from, particularly when we show we can reduce non-elective hospital admissions.

Gold standard treatments don’t remain the gold standard forever. Why would we leave patients on old treatments when we’re putting newly diagnosed patients onto new treatments? It’s time to upgrade care and make prevention and enhancing patient outcomes the focus because a prevention-led focus heads off workload.

Read my blog here on how to grab the attention of NHS decision makers

A patient on optimised treatment doesn’t add any pressure to the system

What do we want to invest in – prevention or hospitalisation? This links wholly to the current commissioner agenda, where ICB commissioners tell me they have four priorities:

1.      Delivering financial balance.

2.      Managing all-year-round workload pressure.

3.      A&E waiting times.

4.      Ambulance response and handover times.

If I want to talk to commissioners, I address one or more of those things. Improving treatment is woven through the operating framework this year. A patient on optimised treatment doesn’t add pressure to the system, so it contributes to the journey toward financial balance.

In February and March I had contract meetings with hospitals postponed because they couldn’t take clinicians away from the coal face because of the pressure on the system.

In one instance they were telling me: “Scott, right now I’ve got a 10-hour wait in A&E, I’ve got 28 patients around the department on trollies, I’ve got 19 ambulances queued up in the car park and I’ve got a three-day wait to get an empty bed in the hospital.”

The only way out of that is clearing the beds to alleviate the pressure on the cubicles and trollies, which then eases the pressure on the ambulance handover time and the waiting time in A&E.

It’s a tough ask, but doing what we’re doing currently isn’t working, and it takes me back to something we’ve talked about before.

Unless the customer is going to say they are 100 per cent happy with all their outcomes – workforce, workload, care delivery, existing pathways, patient demand – then what are they going to change? They have to find the time and space to do it.

That might mean phasing projects over longer periods or finding new and innovative ways of working.

For example, by the time you’ve knocked out August for the holiday season, December for Christmas and March in primary care as they approach the Quality and Outcomes Framework year end, you’ve got nine or ten months to deliver your project.

But you can then look at the audit, divide up the patients across nine or ten months, work out how many a week that is and start to plan how to schedule the appointments.

If you work with primary care networks or general practices, you also have the option of enhanced access hours: 6.30pm to 8.30pm Monday through Friday and 9am to 5pm Saturday.

That also means you’re taking away the work from practices and bringing it into the network, which often goes down well with the practices.

Start small but dream big

I had an audit up in the north east of England where they had 484 patients. We reviewed ten patients a week over 48 weeks, they split the work out across the team, they added one appointment per clinic in this particular disease and they cleared that audit and got everyone optimised.

It’s not always that easy – but I would say surely we could find one ICB in England that could pilot this with support from NHS England. It’s either that or we risk continuing overspends and healthcare professionals still drowning in workload.

If we start small and see how many appointments, referrals and non-elective admissions we have after a year, could we take whatever we’ve learned and scale it out across the other 41 ICBs?

I’m open to other ideas but I come back to what I said at the outset – is it now time that we say the  implement of NICE guidance should be mandatory? And if not, then what are we going to do differently?

Scott McKenzie helps pharmaceutical, medical technology and appliance firms get their products and services in front of the right NHS decision makers. He helped to land no fewer than 53 new projects with the NHS in 2023 alone and has now developed a 12-month mentorship programme that helps individuals and teams get straight to the heart of the challenges of selling to the NHS. If you want to get your products fully embedded into treatment pathways, Scott can help. Get unprecedented access to key customer insights, proven tools, resources and strategies plus 1-2-1 coaching and decision-maker introductions to finally get your project over the line. Find out more here.