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Since it was established in 1999, the National Institute for Health
and Clinical Excellence has made considerable progress towards reducing
regional
variations in access to medicines across England and Wales.
According to Healthcare Commission figures published last month, 85 per
cent of health care organisations report that they conform to NICE technology
appraisals and take into account nationally agreed guidance when planning
and delivering care.
However, it is likely that these self-reported figures
fail to represent accurately the situation in practice, since anecdotal
reports and clinicians’ experience suggest that implementation
of guidance can still be slow and patchy, resulting in wide regional
differences. Variations
Select Committee inquiry
Since February 2007, the House of Commons Health
Select Committee has been conducting an inquiry into the work
of NICE and last month
it heard its last scheduled evidence.
Over five oral evidence sessions,
the committee has been examining, among other issues, the consistency
with which NICE’s recommendations are implemented and the
reasons for failures to put them into practice.
The committee is
due to publish a report of its findings within the next few months. |
At the recent Health Select Committee inquiry (see Panel right), Andrew
Dillon, chief executive of NICE, said he recognised that it
is disappointing when service provision and the availability of technologies
vary
regionally for no reason.
He emphasised the work that NICE has done to
support
NHS organisations and individual health professionals to put NICE
guidance into practice.
However, he also stressed that each primary care trust is in a unique
position, in relation to what it has to do and the money it has to
do it with. It therefore cannot be assumed, he said, that all organisations
start from the same position, or that they can reach the same targets
in the same time. What was important, he said, was to know how each
is
planning to fulfil its obligations under NICE.
In fact, there can never be complete uniformity of service provision, Dame Gill Morgan,
chief executive of the NHS Confederation, argued. Health services
have not developed in a rational, planned way,
but in response to how decisions have been made locally and the geography
of particular areas, she said.
Even if uniformity were possible, it would be a bad thing, she argued,
because delivering all services and care in the same way across England
and Wales would mean services were delivered inappropriately in many
areas. She argued that there is a basic problem with the notion that
postcode prescribing needs to be eliminated, because it is difficult
to establish which regional differences are a result of innovation
and local tailoring of services and which are the result of inappropriate
variations. Costs
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One reason cited for patchy or delayed uptake of NICE guidance is the
cost of implementing it. Primary care trusts make a number of complaints:
• the
medicines that NICE approves are too expensive
• NICE tends to focus on
assessing new medicines rather than treatments used by the NHS day-in,
day-out
• implementing NICE guidance means other treatments, which
may represent better value, are forgone
The cost of implementing NICE guidance represents a small proportion
of the increase in costs to the NHS, Simon Reeve, policy lead for NICE,
revealed. The cost of all the technology appraisals and clinical guidelines
so far issued by NICE is now £1.2bn a year. This accounts for only
3 per cent of the growth in NHS costs over the same period.
Nevertheless, NICE’s approval of a number of expensive medicines
has proved controversial and the inquiry heard a number of criticisms
of the institute’s use of the price per quality-adjusted life year
(QALY) to assess cost-effectiveness of medicines. NICE says that it uses
QALYs as a tool, not as a rule, but that medicines with QALYs of £20,000–£30,000
are usually approved, while those costing more need special justifications
for approval.
However, Raymond MacAllister, chairman of the use of
medicines committee at University College Hospitals London, pointed out
medicines could easily
have QALYs in this range and not themselves be cost-effective compared
with other products for the same indication.
In addition, figures of £20,000–£30,000 appear to be
far higher than those primary care trusts routinely pay per QALY. Analysis
by Peter Smith of the centre for health economics at the University of
York has shown that PCTs spend around £12,000 to secure an extra
QALY in vascular diseases and £19,000 in cancer. John Appleby,
chief economist at the King’s Fund, questioned the reliability
of these figures, but stressed that the current NICE threshold has no
empirical evidence supporting it and no real theory behind it, even though
the issue of the cost effectiveness threshold was fundamental to delivering
equity in the NHS.
The issue of affordability and the overall size of the health budget
cannot be unrelated to the appropriate level of threshold, argued Stirling
Bryan, of the Birmingham University health services management centre.
In thinking about how to establish a cost-effectiveness threshold, one
would, he suggested, start with the overall level of expenditure, then
calculate the cost of providing each treatment, working through each
in order of cost-effectiveness until the budget is exhausted.
Such a calculation is only possible, however, if the value of treatments
currently provided is known. At present, it is often perceived that treatments
approved by NICE are taken up at the expense of established treatments.
And,
even if NICE concentrated more on the assessment of established treatments,
an evidence bias would still favour the approval of new medicines,
which have been through extensive clinical trials, over treatments
whose value and cost-effectiveness may not have been examined so rigorously. No escape
The evidence heard by the Health Select Committee inquiry underlines
the fact that the NICE system is not without its faults, in both
its design and its execution by NICE itself and by PCTs. However, Mr
Dillon
emphasised, the problems that NICE was established to tackle are
not likely to melt away any time soon.
The industry will continue to develop new and valuable medicines,
even if it is a challenge for health systems to pay for them, and
NICE does
not allow England and Wales to escape from that problem.
But, he argued,
the NHS is in a far better place to make the right decisions about
how to apply resources, however limited they might be at a local
level, with
the benefit of the kind of evaluation that NICE does, than it would
be without that evaluation, struggling to make decisions with inadequate
information. |
The
Pharmaceutical Journal