Memorandum by Lambeth, Southwark and Lewisham
Health Authority (NC 47)
1. SUMMARY
1.1 In response to this request from the
Select Committee we have undertaken a brief consultation exercise
across the local health economy in order to provide a collective
approach to some of the questions raised during this inquiry.
1.2 One of the key outcomes of our consultation
has been the need to recognise the existing tension that exists
between national guidance and local need. On the one hand we recognise
that post-code prescribing should be abolished. On the other hand
we have local priorities which need to met. Local health economies
need flexibility to allow an effective approach to this tension.
1.3 For the purposes of this response we
have concentrated on the following two points asked of us:
— Has NICE ended confusion by providing
a single national focus?
— Is NICE providing guidance that is
locally owned and acted on in the right way?
1.4 Our two main recommendations are:
If the government wants a single national focus
and wishes guidance to be owned and implemented consistently,
then NICE recommendations will:
— have to be priced appropriately;
— be included and transparent within
the Comprehensive Spending Review discussions;
— come with full earmarked funding
so that local commissioners can meet local needs without distorting
existing priorities and allow for differential needs and priorities
to be addressed.
To increase local ownership and implementation
of NICE guidance, what NICE considers is of crucial importance.
A full consultation process with health care commissioners, providers
and patients should be undertaken when deciding NICE's portfolio
of interventions as this impacts greatly on what can be achieved
locally.
1. ORGANISATIONS
SUBMITTING EVIDENCE
This evidence is being submitted by LSL Health
Authority to represent the views of its constituent Trusts and
NHS purchasers. The views have been prepared by its Prescribing
Committee and Chief Executives and Finance representatives of
Trusts and Primary Care Groups. Given the timing, however, there
has been limited opportunity to fully consult colleagues.
2. ABOUT LSL
LSL is a health authority responsible for a
population of approximately 730,000 in South London. It has huge
health needs, and despite an annual healthcare budget of over
£900 million finds difficulty in adequately meeting all the
healthcare requirements of these needs. LSL has six Primary Care
Groups, shortly to become three Primary Care Trusts. It also has
three Acute Teaching Trusts (Guy's and St. Thomas', Kings', University
Hospital Lewisham), one Community Trust (Community Health South
London) and one mental health trust (South London and Maudsley)
3. THE BENEFITS
OF NICE
We welcome the setting up of NICE. The independent
assessment of the evidence into the efficacy and appropriateness
of new drugs and interventions has provided clarity and eliminated
duplication of this work by health authorities. The centralised
approach to these assessments that NICE now provides has also
provided welcome standards in how these assessments are done,
although we do not agree that Randomised Controlled Trials are
always the only gold-standards.
4. NICE GUIDANCE
ON DRUGS
VS LOCAL
PRIORITIES
5.1 We have chosen to concentrate on this
as this is the area in which we have collectively done the most
work locally.
5.2 Our main concerns relate to affordability
and prioritisation of drugs for our local population in relation
to need (table 1). The NICE portfolio of drugs does not reflect
our local needs and priorities as shown in table 2.
Table 1
THE LOCAL NEEDS OF LAMBETH, SOUTHWARK AND
LEWISHAM
| Areas for which the burden of disease is above the England average, which might need additional investment
|
| Asthma |
| Chronic liver disease and cirrhosis |
| Coronary heart disease and stroke |
| Diabetes |
| Infectious diseases |
| Mental health problems inc. suicide |
| Pneumonia |
| Sexual health problems |
| Thalassaemia and sickle cell disease |
Table 2
KEY HEALTH PRIORITIES OF EMERGING PRIMARY CARE TRUSTS
COMPARED WITH TOP NICE PRIORITIES
| Lambeth | Southwark
| Lewisham | NICE*
|
| Coronary Heart Disease and stroke | Coronary heart disease and stroke
| Coronary heart disease | Cancer
|
| Sexual health | Sexual health
| Sexual Health | Obesity (also prevents CHD)
|
| Older people | Older people
| | Rheumatoid arthritis
|
| Mental Health | Mental health
| Mental Health | Hepatitis C
|
| Children | Diabetes | Diabetes
| Acute CHD |
| | Disabilities
| | Alzheimers disease
|
*Priorities derived from proportionate increased NHS spend
implied by guidance from March 2000.
6. BALANCING NICE GUIDANCE
AGAINST OTHER
COMPONENTS OF
PATIENT CARE
6.1 Drugs are not necessarily the most important component
of treatment and care from patients' perspective and should be
considered as part of the overall care pathway for treatment.
Local health services need to get the right balance of care and
spend for the patients between acute and primary care and to ensure
that patients receive the appropriate components of their treatment,
which are not necessarily drug-based. For instance, mental health
rehabilitation may be more important for some patients than drugs.
6.2 We need to be able to deliver a pattern of care appropriate
to locally assessed needs an example is given from a study to
map services for people with Multiple Sclerosis and to identify
priorities for further investment. It identified the views and
needs of 40 patients with Multiple Sclerosis living in LSL in
1997/8. It was undertaken on behalf of the MS review group, composed
of patients and professionals.
Table 3
EXAMPLE OF PATIENTS' FUNDING PROIRITIES COMPARED WITH
OBLIGATION TO FUND NICE GUIDANCE
| MS Study - patients' determination of their needs: priorities for funding
| NICE guidance: priorities for funding
|
| Counselling at the time of diagnosis | Beta interferon
|
| Information and education, possibly from an MS nurse
| |
| Transport to and from outpatients and physiotherapy
| |
| Benefits advice and aids |
|
| MS Specialist nurses |
|
6.3 When asked about whether they wanted beta interferon
which had been licensed in 1996, most patients said that they
wanted more information, but not necessarily the drug as the only
top priority. Although the results of this study are now outdated,
the process illustrated that whilst the media suggested
that all MS patients wanted the drug, that was not the case locally.
7. RESOURCE PRESSURES
OF NICE IMPLEMENTATION
7.1 Last year we experienced extreme pressure on resources
locally. Because we have a huge burden of need to meet locally
we were only able to allocate £2 million above inflation
to meet the additional cost of new drugs including those recommended
by NICE (excluding cancer drugs for which we had a separate allocation).
This meant a shortfall or of £2.6 million. This budget has
been exceeded in primary and secondary care. Indeed, we used a
rationing process to ensure distribution of our funds to those
conditions of greatest need and to achieve financial balance in
the local health economy. In secondary care we were only able
to guarantee to meet the costs of two categories of new drugs:
glycoprotein inhibitors and drugs for renal transplants; and partially
guarantee atypical antipsychotics for severely ill psychiatric
patients.
7.2 This year NICE guidance must be fully implemented.
Full implementation of NICE guidance would require rationalising
or cutting-back on other services and developments including meeting
all the key targets within the NHS Plan. We have calculated that
NICE implementation all expected NICE guidance will place an additional
cost on us of approximately £15 million in the financial
year of 2002-03.
7.3 The requirement to fully fund treatments recommended
by NICE, will prevent us from funding other treatments needed
by our local population but which are not yet subject to NICE
guidance. An example is the new disease modifying anti-rheumatic
drugs. NICE has approved the use of virtually all the drugs it
has examined so far[2].
8. THE NEED
FOR EARMARKED
FUNDING
8.1 We are currently preparing for next April's annual
development plan (previously Service and Financial Framework)
and have increased growth money for the NHS. However there is
no earmarked funding for NICE guidance and this is not one of
the priorities in the Priorities and Planning Guidance, except
for cancer.
8.2 In the absence of earmarked funding for NICE implementation
local organisations face major problems and are likely to tackle
them in different ways. Some Trusts feel that this is a commissioner
problem. Others feel that in the absence of full funding they
may be unable to sanction prescribing, because of their statutory
requirement to achieve financial balance. Chief Executives of
Trusts need to reserve the right not to fully implement the guidance.
8.3 If the guidance is not fully implemented with earmarked
funding there will be different decisions in different places.
This will result in "post-code prescribing".
9. OTHER CONSIDERATIONS
OF NICE IMPLEMENTATION
9.1 Ethical dilemmas; This health authority held a conference
to examine ethical and legal issues surrounding such decisions.
The Chief Executive of NICE attended to make a presentation. The
outcome of the conference suggested that NICE guidance alone could
not end post-code prescribing, it was up to local determination
as to how to prescribe or fund it. Legal opinion suggested that
at that time NICE guidance was guidance and that health authorities
and others were entitled to take the total resources available
to them into consideration in deciding their priorities. As long
as they had an explicit process for decision-making, which involved
applying specific values and was transparent, that would be permissible
even taking into consideration the requirements of the Human Rights
Act.
9.2 Timing of determinations: If a determination is expected
it should be available before prescribing or the new technology
has diffused into practice. Further delay can occur if the guidance
is subject to appeal. An example in both instances is the prescribing
of beta interferon.
10. CONCLUSIONS
In summary this health economy:
— welcomes the robust appraisals of NICE;
— regrets that it cannot afford to fully implement
prescribing of NICE recommendations without cutting back existing
services and developments;
— considers that other services or interventions
including drugs may have a higher priority locally for funding
than NICE guidance and so there should be local determination
of funding priorities;
— wishes the timing of determinations to be more
appropriate.
11. RECOMMENDATIONS.
11.1 If the Government wishes to end post-code prescribing
so that all of similar need should have access to similar treatments
around the country, then:
— specific funding needs to be provided to fully
fund NICE guidance;
— prioritisation of what NICE examines is crucial
now that guidance is binding. Drugs or interventions should be
chosen as those most likely to meet major needs rather than those
which, for instance, pharmaceutical companies are about to produce.
The selection process needs to widely involve healthcare commissioners,
providers and patients;
— there should be recognition of the need to prioritise
local needs for health economies which have significant health
problems.
11.2 If the Government wishes to allow new technologies
or drugs to be funded by the NHS until they have been found to
be sufficiently effective and appropriate then:
— No drugs or technologies turned down by NICE may
be used in the NHS; but
— Guidance on those technologies which are recommended
by NICE can be used locally as guidance, but the determinations
should not override local assessment of what is most important
to patients and to meet local needs.
11.3 If the Government wishes to use NICE to appraise
new interventions about to diffuse into practice:
— The determinations need to be available before
the interventions have actually diffused into practise.
— For new drugs this may mean that they are formally
"on approval" or given a provisional NHS funding approval
in possibly selected centres, until determination is available;
or
— For new technologies, they are only carried out
selectively at specific approved centres until determination
11.4 A compromise position which would allow the Government
rightly to end postcode prescribing of essential treatments but
would allow some local discretion in funding priorities would
involve:
— A limited number of determinations would be very
carefully chosen as vital to the population's health.
— The process would be very important and should
be explicit and the responsibility of DH, not NICE. It would need
to involve providers, commissioners and patients. There may have
to be a maximum number of such interventions or maximum total
proportion of a notional PCT budget which would be likely to be
represented by these drugs in total.
— Funding these interventions would be mandatory,
regardless of where patients live.
— Other guidelines/determinations would be used
locally in decision-making processes but their use would not be
binding.
11.5 Our main recommendation is that if the government
wants a single national focus and wishes guidance to be owned
and implemented consistently, then NICE recommendations will have
to be priced appropriately and come with full earmarked funding
to allow local commissioners to meet local needs without distorting
existing priorities and to allow for differential needs to be
addressed.
January 2002
2
Raftery J NICE: faster access to modern treatments? Analysis of
guidance on health technologies. Back
| 
