A response to NICE on their lack of urgency to act on environmental sustainability

In August, we wrote to NICE asking them to urgently increase the emphasis you place on environmental issues, particularly in providing guidance to the NHS on environmental issues and assessing technologies available in the NHS.

NICE responded, agreeing with us that climate change and the destruction of nature are major threats to global health and that action is needed urgently. In their letter they shared updates of work they had already or planned to take forward.

Here is our response.

Dear Janet,

Thank you for your response to our letter on behalf of Sharmila Nebhrajani, chair, and Dr Sam Roberts, chief executive of NICE.

We circulated your response among ourselves and the trustees of the UK Health Alliance on Climate Change, and what follows is a response from all of us.

You say that you recognise that action is needed urgently on the climate and ecological crisis, but your response has no sense of urgency but rather of continuing prevarication.

It was 2015 when the Centre for Sustainable Healthcare first contacted you. We find it disappointing that you have made such little progress in almost a decade. 

Your own recommendation is to “Ensure full transparency regarding any decisions made in the context of healthcare and environmental sustainability.” Yet you are failing to do that.

You write that: “Our findings reconfirmed that the data and analytical standards around environmental impact data about individual healthcare products are not yet sufficient for us to consider sustainability routinely in all NICE technology evaluations.”

This has been the issue for many years because there is no incentive from NICE and others for data and analytical standards. The manufacturers of those healthcare products are looking for guidance on the analytical standards around environmental impact data, and the NHS wants those in procurement to consider environmental impact. 

NICE is in a position to be able to provide these standards. We acknowledge that this is not a simple task, but it is certainly not impossible and there is an urgent need to begin this work because it will take time. 

We know that some pharmaceutical companies would welcome NICE introducing environmental judgements. If NICE were to do so it would provide a business incentive to produce greener medicines. 

Are you aware that the Ministry of Health in Spain has already introduced environmental judgements into its health technology assessment. https://diariofarma.com/2024/07/02/sanidad-incorporara-criterios-ambientales-a-la-evaluacion-y-financiacion-de-medicamentos  If Spain can do it, why can’t NICE?

We know that health technology assessment organisations across Europe are working on environmental assessment, and we hope that NICE is participating in that work.

And are you aware of the Medicine Carbon Footprint Formulary, a free tool that gives the per dose carbon footprints of thousands of medicines? They are rated low, medium, high, and very high. https://formulary.yewmaker.com/about

Are you allowing the best to be the enemy of the good? Would it not be better to start with criteria that are “good enough” and steadily develop them? This approach seems preferable to doing nothing when the climate and ecological crisis is accelerating and the NHS needs to reduce its carbon footprint on all that it directly controls by 80% by 2028-2032.

You also write that you have “identified several potentially impactful activities worthy of further consideration in the short term.” You then tell us about one of them, but can you tell us the others?

You write: We’re exploring the feasibility of evaluating the environmental impacts of competing medicines or health technology products that have little or no expected difference in health or cost outcomes. If we can identify a suitable approach, we’ll look to conduct a pilot evaluation.”

We agree that it should be easiest to incorporate environmental issues when products are similar in health benefit and cost, and we suggest that if you had such a system you would not have allowed desflurane into the NHS. But then you have two qualifications. Firstly, “if you can identify a suitable approach:” the “if” suggests that you think that it may be impossible. That surely cannot be the case. Secondly, if you can identify a method you will “look to a pilot evaluation.” Why so cautious if the health and cost benefits are the same between the two products?

We wonder if NICE is so cautious because of fear of reactions from government, pharmaceutical companies, health device companies, and the media. Can you assure us that this is not so?

We repeat that we are disappointed by your lack of urgency on an issue you recognise as urgent, and we hope to see rapid developments in you incorporating measurement of environmental impact into your work. 

We want to be helpful and would like to meet with your chair, chief executive, or senior people. Will that be possible?

Yours sincerely

Richard Smith

Chair, UKHACC

PS. We plan to post our letter to you, your response, and this letter on our website. We will be happy to post any response that you make to this letter.