The British Psychological Society welcomes the opportunity to contribute to the committee's inquiry into the Aspect of Work of the National Institute for Health and Clinical Excellence (NICE). The British Psychological Society has a keen interest in the work of NICE and along with the Royal College of Psychiatrist jointly sponsors the National Collaborating Centre for Mental Health which produces clinical practice guidelines on behalf of NICE. The Society's comments will address the work of the Collaborating Centre its particular focus on mental health and also the specific areas of interests that are raised by the committee in its invitation to submit comment.

  The Society is the learned and professional body, incorporated by Royal Charter, for psychologists in the United Kingdom, has a total membership of over 45,000 and is a registered charity. The key Charter object of the Society is "to promote the advancement and diffusion of the knowledge of psychology pure and applied and especially to promote the efficiency and usefulness of members by setting up a high standard of professional education and knowledge".

SUMMARY

—  NICE guidance has have brought significant benefit to patients and practitioners and in particular has effectively promoted evidence based psychological interventions.

—  We doubt whether NICE guidance has been increasingly challenged but recognise that some guidance has attracted significant adverse publicity.

—  Public confidence is difficult to estimate but professional confidence and patient support for guidance particularly in mental health remains strong.

—  The evaluation process seems methodologically rigorous but questions about the evidence base and the applicability of measures like QALYs to mental health and the needs of carers need further development.

—  Speed of publication of NICE guidance has been slow but his could be address by narrowing of the scopes and a focus on "how to do" as well as condition focused guidance.

—  The appeal system seems to be fairly robust and works well.

—   NICE compares favourably with SIGN but could learn from some aspects of the SIGN method.

—  Implementation remains the major challenge and there are concerns that mental health generally, and psychological interventions particularly, are being disadvantaged by current commissioning and funding systems in the NHS.

INTRODUCTION

  The British Psychological Society's interests lie in the promotion and public understanding of psychological science and in the case of NICE its application to the health care field. Overall the Society take the view that the work of NICE over the past 5 or more years has made a significant contribution to the effective the use of psychological theory and practice in the effective delivery of health care. The Society believes that this has been achieved in a number of ways but principally through the promotion of psychological interventions, and psychological understanding in the treatment of mental disorders. The large majority of NICE mental health clinical guidelines place psychological interventions as priorities for implementation. In addition of other NICE guidance, for example the Technology Appraisals and more recently Public Health Guidance, the importance of psychology in promoting health for example in the development of effective interventions for at risk children, or in using psychological theory and practice to promote health behaviour change across a range of disorders has also been recognised. We very support the National Collaborating Centre for Mental contribution to the work of NICE and believe that it has not only made a major contribution to the promotion of the general health and wellbeing of the population but has also make a significant contribution to the setting of standards and development and education of a broad range of health care professionals including applied psychologists.

  The committee raised a number of questions in its invitation to submit evidence which we address below.

WHY ARE NICE'S DECISIONS INCREASINGLY BEING CHALLENGED?

  We are aware and have indeed commented on a number of controversial pieces of guidance from NICE, for example the recent TA on the cholinesterase inhibitors in dementia or Heceptin in breast cancer. Whilst it is clear that some decisions by NICE have been controversial and have indeed attracted significant adverse comment we are unconvinced that the number of decision NICE makes are in fact increasingly being challenged. Our understanding is that the level of challenges issued to NICE are broadly in keeping with the number of guidelines issued over the years.

IS PUBLIC CONFIDENCE IN NICE WANING?

  As a professional body our comments primarily reflect the interests of the profession and the implications for psychological science. We have two comments to make in this area. First, NICE guidance has been broadly welcomed and supported by psychologists working in health and social care and they have seen it as a key element in raising standards and promoting psychological interventions. In addition in relation to the work on psychological interventions, NICE guidance has gained considerable credibility and support from the wider service user movement who for some years have been arguing for more extensive psychological interventions not just in mental health but across a wide range of disorders. If there has been any waning in public confidence in NICE guidance we would speculate that the occasional and adverse publicity attracted by a small subset of guidance and its biased presentation in the media may have had an adverse effect but others may be better placed to judge this.

IS NICE'S EVALUATION PROCESS EFFECTIVE AND ARE ANY GROUPS DISADVANTAGED BY IT?

  We think that the methods chosen by NICE are rigorous, transparent and stand scrutiny by any international standards. We feel that these evaluation methods apply best to studies of the effectiveness of interventions but are less well developed when looking at prognostic or diagnostic indictors and we would think that further development is required in this area. There is also some difficulty in application of some NICE methods to the evaluation of certain health care interventions. For example, many of the quality of life measures developed for general health care do not operate, we believe, as well in the area of mental health and we think that they are also not as effective or well developed more generally for certain groups, for example carers.

THE SPEED OF PUBLISHING GUIDANCE

  The speed of publishing guidance as at time caused significant difficulties. In part we understand that some delays have arisen from the appeals procedure or the requirement for more detailed analysis of the evidence than was envisaged in the original scope but in other instances for example in the development of clinical practice guidelines, there have been delays due to extended development times. In part we suspect that this has arisen from the very broad scope of some of the guidance, for example depression or multiple sclerosis. We think that the process may have speeded up and we understand that the refinement of existing procedures, for example the adoption of Single Technology Appraisals, will have contributed to this. Further improvements may be obtained by the adoption of more limited scopes, for example focusing on an aspect of depression such the treatment of depression in primary care or treatment resistance depression. Alternatively using an approach based not on a condition or diagnosis specific approach but looking at the application of a suit of technologies such as NICE recently did when looking at psychosocial interventions in the treatment of drug misuse may also help. Crucially to the success of such approaches will be a more refined process for the identification and specification of the scopes.

THE APPEAL SYSTEM

  We have had very limited involvement in the appeal system. Our impression is that this system is well run and seems in our opinion to give a fair view to all sides involved in the appeal.

THE COMPARISON WITH THE WORK OF SIGN

  Our experience of both organisations is limited to the production clinical guidelines. There have been relatively few guidelines in the same area. Our comment would be that whilst the two processes are broadly similar, that there are aspects of the SIGN process that, for example their formal consultation meeting with stakeholders in the development phase that could potentially be adopted by NICE. However, our overall view is that on average the general rigor and thoroughness of the methods which NICE has adopted confers some advantage in terms of the final product.

THE IMPLEMENTATION OF NICE GUIDANCE

  This is our major area of concern. NICE has produced a considerable body of compelling evidence which we believe has major implications for health care. However, from the point of view of the Society aimed at promoting psychological practice we have a number of concerns. These could be broadly summarized as follows:

(a)  Mental health guidance appears not to have had the same general support for implementation as other health guidance. In part this make stem for the fact that mental health guidance has been disproportionately represented in clinical guidelines as opposed to technology appraisal but we believe it may also it also reflect weaknesses in the commissioning and funding of mental health services. It is our impression that overall structures and supports systems for mental health commissioning are somewhat weaker than those for general healthcare commissioning.

(b)  It is noticeable that some criticism of NICE guidelines refers to the possible negative consequences of NICE recommendations acting as inviolable mandates on practitioners. In the field of mental health, NICE guidelines routinely call for psychological interventions, which are often not available in NHS Trusts. This disparity is not lost on the users of mental health services, who already feel they are the recipients of "Cinderella services".

(c)  The lack of a mental health tariffs under PBR may also have further reduced the incentives to support guideline implementation in mental health.

(d)  We welcome the recent work by the Healthcare Commission focusing of the implementation of the schizophrenia guideline which focused in part about psychological interventions but we are very concerned that despite the emphasis given to psychological interventions on NICE guidance and is supported by other initiatives such as the DH programme on Improving Access to Psychological Therapies implementation of guidelines remains weak. There are a number of reasons for this and these include the reluctance of healthcare commissioners and services to adopt the proper services delivery structures to support effective implementation; the lack appropriate training (funding for clinical psychology training this year has been reduced) and the lack of appropriate supervision and support structures for postgraduate training. We believe that these represent a significant impediment to the implementation of NICE guidelines.

The British Psychological Society

23 March 2007