The Pharmaceutical Journal
Vol 269 No 7206 p59
13 July 2002

Professor Sir Michael Rawlins addresses 10th anniversary conference

Professor Sir Michael Rawlins, chairman, National Institute for Clinical Excellence, gave the key note address at the Pharmaceutical Care Awards conference.

He explained to the assembled health professionals how NICE makes decisions about the technologies it appraises and how patient need is the number one criterion in the institute's deliberations.

In producing guidance, NICE is expected to take into account both clinical and cost effectiveness, Professor Rawlins said. In addition, NICE must consider the consequences of using the technologies on other available resources and the impact of decisions on innovation. "It would be very easy for an organisation like NICE to be so inflexible, to require such rigid standards of evidence, as to impede seriously innovation."

NICE also has to take into account guidance from ministers on available resources, he said. In theory something could be deemed to be clinically and cost effective but not affordable.

Professor Rawlins said that NICE is often asked to review trials designed for licensing purposes where the comparator is placebo. "To know what we are getting in terms of added benefit may not be apparent."

The most helpful measure of cost effectiveness is cost utility, said Professor Rawlins. He explained that this was the cost per health gain, taking into account not just quantity of life but also quality. The most common measure is the cost per quality adjusted life year or cost per Qaly.

Although NICE has rejected some expensive (in terms of cost per life year gained) technologies, for example, oxaliplatin and irinotecan, a threshold is not applied. Professor Rawlins explained that the probability of rejection increases as the cost per Qaly gets higher but that the driver is clinical need. There are instances where two technologies have a similar cost per Qaly, for example, zanamivir for all patients and riluzole, but one is rejected and one approved.

It would be inappropriate to set a threshold for cost effectiveness in terms of cost per quality of life year gained because this measure does not take into account clinical need, he said.

Awards allow pharmacists to extend care

Receiving a Pharmaceutical Care Award has meant that pharmacists have been able to extend the care they offer and to develop their work, Dr ANGELA ALEXANDER, a care awards judge and chairman of the College of Pharmacy Practice, said at the awards. She added that it was often at local level that some of the innovatory developments got off the ground allowing individuals to prove their worth and demonstrate the potential for an initiative to be taken forward as a national service.

This was very much in evidence in the 1999 award winner — the Manchester project for provision of emergency hormonal contraception, Dr Alexander pointed out. The service was provided locally from a small group of community pharmacists before it was made available nationally. "This was a good example of where the Pharmaceutical Care Awards can act as a catalyst for change."

In the same year, the winner in the hospital category was a project that involved pharmacist prescribing of discharge medicines. "This may have been an important forerunner to the supplementary prescribing that we're about to see." Furthermore, before the recognition of clinical governance, awards were presented for projects that were examples of good practice in clinical governance.

A previous award winning project — pharmaceutical care assessments for high-risk patients in Colchester — had in the past two years moved on from being a small local pilot project to being a routine local service. The service was cited in the National Service Framework for Older People as an example of good practice.

Dr Alexander said she believed the awards had nurtured a patient oriented approach. In 1992, the first year of the awards, one of the prize winning entries had been a scheme to provide a self medication system in an oncology hospital. This project gave patients greater control over their medication, helping them to maintain their independence. "All these examples have really built the pharmacist's role into what we all, as pharmacists, believe it should be," she added.

Good practice needs to be emulated

Some of the ideas explored in the Pharmaceutical Care Awards by pharmacists 10 years ago are now embodied in government policies, CHRIS TOVEY, director of retail operations, GlaxoSmithKline, told guests at the awards dinner. "Through entries to these awards, pharmacists have shown their flexibility and commitment to taking up the challenge of an enhanced role in health care in the United Kingdom," he said.

As local pharmaceutical services develop, supplementary prescribing becomes a reality and medicines management becomes increasingly common, the good practice shown in these awards will need to be emulated across the pharmacy community.

Mr Tovey added that the Government's drive towards greater patient empowerment placed demands upon Government, industry and pharmacists alike. "If patients are to be truly empowered they need to be able to make informed decisions about their own health care management. Our common responsibility is to ensure that they have an adequate information infrastructure to enable them to make the right decisions."

Mr Tovey called for a partnership between the profession, industry and Government. "With increasing patient expectations only true partnership between the profession, industry and Government can ensure that patient-centred care becomes a reality and not rhetoric."