A NICE example? Variation in provision of bariatric surgery in England

The National Institute of Health and Care Excellence (NICE) has been the most ambitious attempt to set healthcare priorities more systematically and explicitly since the inception of the National Health Service in 1948.1 NICE was established in 1999 with the dual aims of reducing regional inequality in access to treatments and making decision making more systematic through explicit consideration of the clinical and cost effectiveness of (mostly) new treatments. Despite controversies related to the time taken to issue recommendations and the defensibility of its cost effectiveness thresholds, the NICE decision making process is respected within the UK and internationally.2 3

Nevertheless, NICE guidance has met with a mixed reaction from NHS commissioners, who have to implement the recommendations, some of which are mandatory within three months. Frustrations have arisen over the lack of consideration given to the affordability of implementation. (NICE recommendations have to be funded from existing allocations, implying disinvestment elsewhere.) Drawing on the example of bariatric surgery for morbidly obese patients, we review the implementation of NICE guidance and regional specialist commissioning guidelines over the past 10 years. We examine how they have affected provision of care and consider what challenges remain for the new clinical commissioning groups and NHS England as they take on their full commissioning roles.