Select Committee on Health Minutes of Evidence

Memorandum by Dr Tim Crayford, Deputy Director of Public Health and Chairman Prescribing Committee, Croydon Health Authority (NC 32)


  1.1  Croydon Health Authority covers a population of about 330,000 people in South West London. It is co-terminus with the Local Authority and will become a large Primary Care Trust, when it merges with the local Community Trust in April 2002.

  1.2  Croydon is a mixed affluent-deprived area, whose demographic cross-section is quite similar to that of England as a whole. It has one major acute provider, Mayday Hospital, and around 75 General Practices.

  1.3  Dr. Crayford is a Consultant in Public Health Medicine, employed by Croydon Health Authority. He chairs Croydon's Area Prescribing Committee (APC), which develops local prescribing policy, and supports local implementation of NICE guidance. Part of the remit of the APC in Croydon is to advise on the relative priority of new drugs, and take an overview of the implementation of NICE guidance relating to medicines. Dr. Crayford is also a member of the Health Authority executive group that decides on purchasing priorities for the health authority.


  2.1  NICE offers a number of helpful functions to those who are responsible for prioritising NHS resources. The centralised sifting through the evidence offers the NHS as a whole an economy of scale. When NICE makes a recommendation not to implement a technology, this has helped where we might have otherwise struggled with a blanket ban. NICE has appointed high-calibre people who have in turn ensured that the membership of the NICE committees is heavyweight and unbiased.

  2.2  Whilst providing detailed clinical guidance that affects whether particular doctors offer treatment to certain patients, NICE's main effect on Health Authorities has been to alter how they prioritise expenditure. Health authorities can only prioritise fairly if all competing demands are considered at once. Because of the way in which it has been set up, NICE does not do this, as it considers new treatments at the margin of healthcare. In contributing to the prioritisation debate in the NHS as a whole, it is therefore flawed. Until NICE has evaluated things like the benefit of funding new nurses for our local A&E department at Mayday Hospital, then its recommendations to fund certain treatments, which are by default at the expense of this sort of development, cannot be rational for local health economies. The full implications of this point suggest that significant reform is required to make NICE fit with overall prioritisation in the NHS.

  2.3  Not all areas of the country have the same priorities. Whilst reducing the postcode lottery for a very few high profile treatments, NICE's judgements can be at the expense of locally supported and needed developments.

  2.4  The proposal to make NICE guidance mandatory will make local prioritisation more difficult than it already is. If all of NICE's guidance is to be mandatory, then NICE should have a top-sliced budget within which it should prioritise its own advice. NICE must assume some financial accountability for its decisions.

  2.5  The one situation where NICE's guidance should be mandatory is for drugs or technologies that are not recommended for use in the NHS. This would still permit the government to say that it is contributing towards the elimination of postcode rationing and would strengthen Health Authorities' or PCTs' hand in limiting access to ineffective treatments. There is an infinite number of things in which we could invest. What we need help with is in excluding things from this list, not lengthening it.

  2.6  There are widespread concerns about NICE's impartiality and bias towards evidence it receives from the pharmaceutical and health technology sector.

  2.7.There is a large legal industry that has grown up to provide the same advice to the many different NHS organisations affected by NICE guidance. This is usually to clarify our liability in being unable to fund NICE guidance fully. It would be sensible that NICE also provided a single legal service to health authorities to help them in circumstances where they are able only to partly-fund treatment.


  3.1  Most commentators agree that the evidence provided is clear and digestible. NICE has occasionally reversed or delayed decisions, and this has made it seem indecisive in some cases.

  3.2  Some opinion considers that NICE guidance lacks credibility. Particular concerns have been that its guidance is not timely and that it listens to biased sources of information.

  3.3  A good example would be that of Implantable Cardiac Defibrillators (ICDs).

  ICDs are relatively new devices that can detect potentially fatal electrical disturbances in the heart and fire a counter electric current to correct them. There is no question that they can sometimes save lives. There is also no question that, at £30,000 per patient, they are expensive.

  There is an alternative medical treatment, using a drug called Amiodarone, which is not quite as effective as these devices. If cost were not an issue, one would almost certainly choose an ICD over medical treatment. The question for the NHS as a whole is whether this additional cost is worth the benefit.

  NICE interviewed nine industry-sponsored groups or companies, and one Professor of Cardiology whose department has been involved with industry-sponsored research in this area. NICE commissioned one systematic (impartial) review of evidence. We spoke to the author of this review. Unlike the many industry representatives, the author had not been interviewed by NICE about their submission prior to publication of NICE's judegment. Furthermore, they reported that their estimates of the cost per year of life saved were "much higher" than those presented by the industry, which they said were used in the report.

  With ICDs "One death in the first three years was averted per 10 patients treated". This seems like a high cost for this sort of intervention. Four of these devices were used in Croydon last year at a cost of around £120,000. At its recent inspection of Mayday, the commission for heath improvement, CHI, identified improvement of A&E services as a major area for improvement. Each of these devices could have fully funded an extra nurse in A&E next year, who would potentially benefit many hundreds of our residents.

  There is little doubt that Croydon Health Authority would not have prioritised funding of ICDs over the provision of basic core services.


  4.1  NICE has unquestionably provided a single, national focus. On the rare occasions that NICE has said "No", it has decreased confusion. On the other occasions, it has still left health authorities with the problem of how to fund the guidance. This has mostly involved partial funding of the guidance, through devices such as clinical budget-setting - i.e. agreeing to fund a certain number of treatments for local residents per year, rather than agreeing to fund all patients who meet certain clinical criteria, which would be the usual way NICE guidance is expressed.

  4.2  What is unfortunate is that in some circumstances, it has paradoxically increased confusion. The delay in resolving the use of Beta Interferon in Multiple Sclerosis has caused us particular problems. Although Croydon would like to issue a blanket ban on the use of this drug for our residents, our legal advice is that because of the "planning blight" caused by the delay, we would be open to legal challenge if we were to do so. So even though the currently available evidence would not support the use of NHS funds for this drug, the delay in reaching a judgement at a national level, has meant that we still have to pay for new patients to receive it.


  5.1  NICE is about national standards for access and by definition is not contributing to local ownership. This is not necessarily a problem. However locally sensitive one would wish services to be, some blatant irrationalities of postcode prescribing should be ironed out, and NICE seems like a sensible vehicle to do this.

  5.2  It is not possible for health authorities to fully implement NICE's guidance without failing to invest in other more needy areas.

  5.3  Most Health Authorities have had to allocate a sum to NICE guidance, which has not been enough to cover the full cost of the guidance itself. Croydon Health Authority for example, allocated £550,000 last year to cover the introduction of new drugs, including those evaluated by NICE. From this, we had to undertake a prioritisation process to decide which drugs were to be funded, which necessarily meant not fully funding some NICE guidance.

  5.4  Where NICE could provide useful guidance to health authorities is by specifying a "due process" that we could follow in prioritising NICE's recommendations for funding.


  6.1  Yes. But the issue for health authorities is not whether the treatments work, it's how much they cost, and specifically the trade-off between the two, usually measured in the cost per quality adjusted life-year (QALY). As the recent review by Raftery has shown, NICE has only considered adequate QALY data in about ½ of the reviews conducted so far. The paucity of adequate data on cost-utility has blighted NICEs ability to provide credible guidance. For all the confusion this has created, it would almost be better that NICE stopped considering cost and simply concentrated on whether or not interventions worked.


  7.1  NICE is about prioritisation in the NHS as a whole. Because NICE has thus far considered just a very few new technologies it has distorted health authorities' purchasing priorities to the detriment of patients.

  7.2  Significant reform of NICE is required to make it fit with prioritisation in the NHS as a whole. What is essential is a frank debate about what the patients of the NHS is for, not just treatments at its margins - similar to the "Oregon" process from the USA. NICE would seem to be a suitable organisation to lead this.

  7.3  NICE should be made financially accountable for its decisions.

  7.4  NICE should be more circumspect about collecting evidence from the industry, from clinicians who have conducted research funded by the industry and from lobby groups.

  7.5  NICE is at its most helpful to health authorities when it says "no". It clearly needs to raise its thresholds for recommending expensive treatments to the NHS.

  7.6  NICE should provide a service to Health Authorities and PCTs about the legal implications of its advice.

January 2002

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