NICE: GIGA (GARBBAGE-IN, GARBAGE-OUT)?
Margaret Williams 24th October 2007
The ME community may be interested in the following quotations about the National Institute for Health and Clinical Excellence (NICE); they are taken from the chapter titled “The new management of scientific knowledge: a change in direction with profound implications” by Professor Bruce D Charlton MD from the Centre for Health Services Research at St Bartholomew’s Hospital, London, contained in the book “NICE, CHI and the NHS reforms: enabling excellence or imposing control?” edited by A Miles, JR Hampton and B Hurwitz (Aesculapius Medical Press, London, 2000).
This chapter discusses NICE, CHI (the Commission for Health Improvement, which worked in collusion with NICE but which ceased existence in 2004 and became The Healthcare Commission – an “independent” watchdog for healthcare, now The Commission for Healthcare Audit and Inspection, which in common parlance is a team of hit-men whose job is to ensure conformity with the NICE guidelines), the “sausage-machine” policy of the NHS and the managerial take-over of clinical practice. It has a particular resonance for people with ME/CFS.
The quotations are not all in chronological order as they appear in the chapter.
“The stage is set for clinical science to be steamrollered by the demands of power politics”.
“NICE is not about science, it is about government and managers attaining the statutory power to control doctors”.
“The supposed benefits of NICE do not stand up to a moment’s consideration. NICE and CHI are organised in the form of a statutory arm of the government bureaucracy, as special health authorities with powers intended to influence the clinical practice of doctors and other health workers”.
“Data input is selective, analysis is selective, and the results are selective. The watchword is GIGA – ‘garbage-in, garbage-out’. Conclusions cannot be stronger than the validity of the database from which they were generated”.
“NICE is almost the opposite of science because it reverses the relationship between theory and clinical experience. NICE seeks not to explain, but to fabricate excuses for the centralised control of medical practice”.
“The credibility of NICE depends upon the claim that NICE guidelines will be objectively valid (i.e.) based on appropriate evidence, properly interpreted, rationally argued, and intellectually compelling. If NICE guidelines are seen to be partisan, irrational, scientifically unconvincing or politically-driven, then NICE guidelines will amount to little more than government propaganda backed up with a big stick”.
“NICE advertises itself as the application of rational and scientific management to medical practice. The claimed intellectual credibility of NICE derives from a raft of data-driven and statistically-based academic disciplines which have become dominant in the past decade. These include Epidemiology, Evidence-Based Medicine, the Cochrane Collaboration and related areas concerning ‘clinical effectiveness’, ‘meta-analysis’, ‘guidelines’ and so on. All of these have been created, sustained and directed largely by Department of Health funding. In return for this funding, the practitioners of these arts have performed a managerial role – aspiring to the function of commissars for government and NHS management. There is no reason to assume that NICE will perform any better than any other government bureaucracy when it comes to providing objective, rational and independent guidance”.
“For NICE guidelines to be credible, it ought to be clear that optimal clinical practice is known, and can be clearly stated in the form of usable guidelines. Presumably, this implies that randomised, controlled trials (RCTs) are intended to be the main source of evidence for NICE, since it is a commonly held belief among the clinically ignorant and epidemiologically unsophisticated that the RCT is capable of providing precise and unambiguous (‘gold standard’) guidance for clinical practice (reference: any publication from the Evidence-Based Medicine movement or the Cochrane Collaboration). Unfortunately for NICE, RCTs cannot provide precise and unambiguous guidance for clinical practice, since most RCTs are done on unrepresentative populations of heterogeneous subjects employing sub-optimal levels of experimental control”.
“Many bio-statisticians hoped that meta-analysis would provide a method for objective interpretation. But this was a delusion, since an accumulation of inadequate data simply makes a bigger pile of inadequate data”.
“It is embarrassing for those who understand statistics and clinical medicine to contemplate the enthusiasm of (the) protagonists (of meta-analysis) and profoundly worrying that their armour-plated credulity has become the orthodoxy among politicians and managers”.
“The failure of RCTs and meta-analysis to deliver objective and authoritative guidelines means that NICE recommendations will inevitably suffer from the same lack of intellectual credibility that affects many other guidelines emanating from the Department of Health sponsored guidelines industry (Centre for Reviews and Dissemination, Cochrane Collaboration etc)”.
“NICE guidelines will differ from existing sources of medical advice only because they will be mandatory, and enforced on doctors by sanctions”.
“NICE and CHI are near the apex of a top-down managerial hierarchy in which the upper echelons audit and control the lower ones. This means that non-practitioners make decisions and enforce those decisions upon practitioners. Power to judge scientific theories in NICE is centralised and concentrated in the hands of the few who give order to be acted upon by the many”.
“NICE re-defines ‘science’ as being whatever is the outcome of its deliberations”.
“Since decisions are in the hands of the few, this decision-making process is readily corrupted by political expediency or self-interest”.
“NICE is designed to dominate professionals, not to assist them”.
“This politicisation of the NHS was to be driven from above by radical ideas emanating from the cabinet and its policy think-tanks, and implemented by a management empowered to impose these upon an unwilling professional workforce, (resulting) in the transfer of power from health professionals to general managers”.
“The superficial aspects of this dominance of policy compose the whole bogus rhetoric of mission statements, aims and objectives, targets, charters, standards, guidelines, protocols and public relations. Clinicians are kept busier then ever on ‘implementing’ reforms. The chaos game is one that only managers and politicians can thrive on: professionals and patients are the losers”.
“ ‘Infostat’ is my term for the use of information technology and statistics to support managerial decision-making. Infostat techniques aggrandize the significance of the larger database and denigrate the value of personal contact with patients (too ‘anecdotal’ and ‘subjective’). Increasingly, clinical training, experience and patient contact are derided as subjective, and marginalized as anecdotal compared with the awesome weight of data. Whatever is not statistically processed is seen as inadmissible evidence. And politicians and management have – through Department of Health funding – ensured that they have a virtual monopoly of such evidence”.
“This means that quantity of data is much more important than its quality. Indeed, politicians and managers are almost indifferent to the real quality of the data. Academic criticisms of validity are water off a duck’s back, since they are entirely subsidiary to the managerial process”.
“In this game, statistics always trump direct personal experience to the point that people are no longer supposed to act upon the evidence of their senses”.
“The political pressures and managerial judgments are shielded from critique by an elaborate façade of pseudo-evidence”.
“The official propaganda for NICE denies the massive role of arbitrary opinion and interest involved”.
“The doctor is not allowed to take notice of individual patients’ needs, wants and preferences – the doctor can only stick to procedure. The medical profession is too strong. The only sensible solution is to destroy the medical profession and force doctors to follow instructions. Doctors’ role in the health service is not to exercise autonomous judgment: the doctors’ role is simply to obey guidelines. The nature of clinical service is no longer to be under the control of doctors, never mind patients, but will be decided by politicians and managers”.
“The ideal of Infostat is not to out-argue opposing viewpoints by scientific evidence, but to bury them under a sheer mass of evidence”.
“In contrast to the ethic of honesty, NICE already exemplifies a fundamental evasiveness by conflating effectiveness with cost-effectiveness”.
“NICE is a diabolical engine that manufactures decisions when fed data. These decisions are legitmated by burying the opposition under a heap of misleading information and obfuscation”.
“Top-down regulation is a branch of management theory, not of human biology. Political expediency will corrupt science”.
“NICE is just part of the NHS sausage machine, a mechanism which exists to support policy decisions and which has little incentive to seek the truth. The policy sausage machine was designed and paid for by politicians and it will be influenced primarily by politicians”.
“Whatever the phony mission statements about ‘clinical excellence’ and ‘health improvement’, the fact is that NICE is a government funded bureaucracy (and its) recommendations will be enforced on doctors by the CHI inquisitors”.
“Since the real function of NICE is to control the medical workforce, as long as there are recommendations to be enforced, then NICE will be serving its political purpose”.
For the full paper, see http://www.hedweb.com/bgcharlton/cargocult.html