Richard Smith: 14 years at the helm of NICE

Richard Smith“You’ll do, but you’re not my first choice,” said Frank Dobson then Secretary of State for Health when he appointed Mike Rawlins as the first chairman of the National Institute for Clinical Excellence (NICE) in 1999. Later the blunt speaking Dobson was asked whether NICE would work: “Probably not—but it’s worth a bloody good try.”  Last week, 14 years after those conversations, Dobson was the first speaker at a meeting to say thank you to Rawlins. who is stepping down from the chair of what it’s not hard to argue is one of the world’s most successful health organisations.

There can be little doubt that Rawlins has been central to NICE’s success. No one, said Dobson, has challenged the integrity of NICE. Many groups have hated NICE—famously described as a death panel by the American politician Sarah Palin—but its integrity has not been doubted. That attribute starts with Rawlins, who has never been afraid to say what needs to be said even when powerful figures don’t want to hear it. Rawlins is also clubbable and despite his posh voice a man of the people. Most of the people at the celebration were the staff of NICE, and the affection and respect they hold for Rawlins was palpable. But Rawlins’s charm covers steel inside, and we can be sure that he has told the six secretaries of state who have been and gone in his time what they needed to hear.

One of the highlights of the meeting was Andrew Dillon, the chief executive of NICE, projecting a photograph in which he was sat with Rawlins trying to explain, we all imagined, why what Rawlins had said or done was at the edge of what was acceptable. Rawlins looked genuinely surprised.

Rawlins began his job with almost nothing. Parveen Kumar, one of the original board members of NICE, described their first meeting where Rawlins had told them that they launched in 90 minutes, but had no office, no chief executive, and effectively no money.  But he’d said how he had somebody outside the door whom he hoped the board would appoint as chief executive because, “If we don’t we’re buggered.” Several speakers described the excitement of “making it up as we went along.”

The success of NICE cannot be doubted, and the credit must begin with its reputation for integrity at a time when so many British organisations— for example, parliament, the BBC, the NHS, the pharmaceutical industry, and the press—have been found out for shocking lapses of integrity. Rawlins reported at  the meeting that Jean Paul Garnier, when he stepped down as chief executive of GSK, a company that had battled with NICE, said to him that eventually all countries would have a NICE and that he hoped they would be as fair as the original.

Its very survival is a signal of its success in a world where some quangos have been abolished within 18 days of starting, and plenty of groups would like to have got rid of NICE. Tony Culyer, another of the founders of NICE, listed the many groups who were threatened by NICE. Politicians might have resented the power it had to make decisions that they might have made. The clinical professions might have felt their autonomy undermined. The pharmaceutical industry, which is very powerful in Britain, has resented NICE since the beginning, and many patient groups have been upset by NICE decisions.

Yet NICE has not only survived it has been given more and more responsibilities. It has absorbed other quangos and had its remit repeatedly extended. In April it will become the National Institute for Health and Care Excellence, becoming responsible for social as well as health care.

And many countries have created their own versions of NICE, and, said Lloyd Sansom, chair of the Australian Pharmaceutical Benefits Advisory Committee, NICE has become an icon in the world of health technology assessment, a world that doesn’t have many and perhaps no other icon.

Rawlins quoted at the meeting, something that I wrote in the BMJ in 2004: “NICE may prove to be one of Britain’s greatest cultural exports, along with Shakespeare, Newtonian physics, the Beatles, Harry Potter, and the Teletubbies.” I was wrong about the Teletubbies, but right about NICE.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.