Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 180 - 199)



  180. You are acting as a mouthpiece for those expert groups.
  (Dr Walker) Yes.

  181. That is fine. That is just what I wanted to clarify.
  (Dr Cunningham) I am in exactly the same position. I do not want to major on the quality of the guidance, because I am not necessarily an expert in guidance. Certainly what we have is very much better than what we had before, which was that we had to do it ourselves. We set up local expert teams and around London you might have had ten different expert teams doing the same sort of appraisals. What we have is very much better. We do have some difference. When we look at NICE guidance which comes out, we have some differences of opinion, for instance we have already mentioned that the cancer collaborative network had already done a lot of work with clinicians all over London, looking at the range and quality of the literature, rating them on strength of evidence, possibly with slightly more health economic data than has been possible to include in some of the NICE guidance. The example where we should have liked slightly more health economic data was Docetaxel for lung cancer. There are slight differences which we might quibble about but basically we very much welcome the fact that there is national robust guidance that we do not all have to re-invent the wheel everywhere. Obviously when guidance comes out, I chair the area prescribing committee which has all the pharmaceutical advisers on it from our local trusts and primary care groups and trusts. It has clinicians, it has academics, it has chief executives of the primary care groups and trusts, it has a lot of people on it. We crawl over it but we really do not think we ought to re-invent the wheel here.

Dr Taylor

  182. A very quick comment. There are public health doctors and public health doctors. I shall not say any more than that. What I should like to draw attention to is Dr Crayford's very good illustration. You gave us the figures and I think the press should be aware of these: four implantable cardiac defibrillators cost £120,000 and for that same amount of money you could have funded four extra nurses.
  (Dr Crayford) Yes, around that.

  183. That is staggering and that absolutely shows the problems you are faced with of prioritisation when these are put on top of you.
  (Dr Crayford) Exactly.

  184. That is really almost the most important message we have so far. Another very quick message to underline is the ethical input which Dr Cunningham implied was lacking. I should love that to go forward. A question: Dr Crayford is very keen on the "not recommended" advice. Do you have advice for how NICE really should be working? How it should relate possibly to the BNF, which is a very authoritative statement of treatments which should be used?
  (Dr Crayford) Yes. The relationship between the introduction of a drug and its licensing, its appearance in the BNF for doctors to prescribe and then guidance associated with its use really needs to go hand in hand and there needs to be much closer inter-connectiveness with NICE and the drugs licensing procedure. That will stop some of the planning blight. Turning to the second part of the question, I have brought along a list of some of the priorities we have had to consider this year in Croydon as a result of the many national initiatives through national service frameworks, through the local modernisation review, which have resulted in bids of £70 million, when we are likely to have as a health authority somewhere between £6 million and £11 million to spend on some of these things. We have to go through a prioritisation and filtering process which weighs up all of these priorities and this is where the issue of implantable cardiac defibrillators is key. The nurses we could put into accident and emergency very directly stack up against some of the things which NICE have funded. When NICE says yes and it is mandatory, it deprives our local residents of the chance of getting core and basic services. Coming back to the point when NICE says no, we have this list of 450 things which we could fund and frankly we do not need a lot more help to say yes to particular interventions, which is often where NICE has come down; NICE has not actually said no. We need help with saying no and with the filtering out process. One of the things NICE has is a standard of cost effectiveness which it attempts to use to decide whether or not to recommend a treatment which is £30,000 per quality adjusted life year. If you will forgive the technicality, that allows a consideration of one treatment against another. There is a real question about where that level has been set, if it is letting things under the wire such as implantable cardiac defibrillators. NICE is very helpful to us when it says no; the trouble is that it does not say it very often. Secondly, where it places its line of when it allows a drug through or not is also quite questionable.
  (Ms Marlow) I am not quite sure of the line of your question but you talked about how NICE should be working. There is a key point about NICE trying to get closer to those who are involved practically in implementing the guidance and getting more feedback about how it is working, how it can be improved, made more user friendly. At the moment there is a bit of a gap there between NICE and the constituents, particularly primary care and GPs.
  (Dr Cunningham) We would completely endorse that. We in our health authority have exactly the same problem as Dr Crayford has and I imagine Dr Walker has but we have far too many things to do which are very important and we cannot even meet the Government's top 20 priorities; we cannot even fund those easily. There are some things like emergency care, getting people into hospitals, reducing waiting times, some of these things which the public think are very important but we shall not necessarily be able to do if we have to fund these things fully. If we have to fund them fully we really want to be very involved in the debate; first of all the selection, what they are going to do; secondly how they consider them and how they consider them as part of a systems' approach and how easy they are to implement locally and all the other things you have to do locally as well as provide a drug. Lots of guidance comes out where you have to do quite a lot of other things locally. Primary care has quite a large capacity problem to implement these.

Mr Burns

  185. Did I hear you say that you feared that things like bringing down waiting lists could be adversely affected?
  (Dr Cunningham) The Government has given an increased uplift to the NHS but it has also given increased targets which the NHS has to work to which all the public and everybody is well aware of. We are required to concentrate on trying to meet those targets. The national planning guidance says in the guidance that we have to meet the NICE guidance requirements in cancer. It does not actually say in the planning guidance that we have to meet the rest of NICE requirements; that is part of a separate guidance. We are struggling in our health authority because we have a huge burden of problems to meet the Government's emergency care and other top priority targets. This requires resource investment and we are having to make exactly the choice that Dr Crayford talked about, whether we invest, what we need to do to meet these targets or whether we fully fund some of the NICE guidance which may be slightly less of a priority locally.

  186. What conclusion have you reached in answering that question?
  (Dr Cunningham) We thought it was a sacking offence not to meet the Government's top 20 priorities.

  187. Presumably that would suggest that if you have problems now, when the 15-month target comes in on 1 April you are going to have even more problems.
  (Dr Cunningham) Yes.

  188. Are you not confident that you will meet that target, so there may be sackings?
  (Dr Cunningham) No; I will not be drawn into that. Obviously we are putting all our efforts into trying to meet these targets locally because we know that is what is required and we are trying to do that. What that means is that we have to concentrate our efforts on those things which will enable us to meet those targets. We also have to concentrate our resources on what will enable us to meet those targets. I do not say we have a problem in meeting the targets, but I do say if we have lots of other priorities coming down as well as these top 20 priorities, then we are going to have problems.

  Dr Taylor: Several of you have said NICE guidelines are mandatory. We rather got the impression last week that that was changing although in the House in debates in July and August Yvette Cooper said they were. One of our witnesses last week at least said that that was changing. Is that anybody else's memory?

Siobhain McDonagh

  189. No; I thought it was the other way and they are becoming more mandatory.
  (Ms Marlow) There was a statutory instrument just before Christmas which made it mandatory.

Mr Burns

  190. Dr Cunningham, you say that there is a tension between "national guidance and local need" and you have skirted around and elaborated in part on that in earlier questions. Do you think this is inevitable? What do you think NICE could do to avoid it or could have done to avoid it or minimise it?
  (Dr Cunningham) When NICE was set up I did not think it was necessarily the Government's intention to make all of NICE guidance binding, so the way NICE chose what it was to look at was not geared up to best meeting the needs of local populations. Some populations have different needs from others. For instance, I come from a population which has in some parts, in the Southwark primary care group, six times the level of psychosis in some of its neighbourhoods compared with the national average. When NICE was set up we thought we would be getting guidance over which we had discretion locally, for instance if we have a huge sexual health epidemic, which we do, a huge burden of mental health disease and maybe not so much in the other areas like cancer. About three quarters of NICE guidance in terms of financial consequence to the NHS appears to relate to cancer and cancer is not as big a problem locally as psychosis might be. When we thought we were getting the guidance, if we had had discretion locally to use the guidance in some areas more than others, that would have been fine. Our problem comes if we do consider that it is binding and we have to fully fund it after three months, it distorts local priorities. It would also not be a problem if it came with funding. If the Government said that NICE guidance was binding and they wanted everyone with the same condition, same need to have the same treatment around the country, that would be fine if places which had a lot of people with those needs got funded more than other places. That, however, does not appear to happen. Also, it would be better if we could influence what they do so that our needs could be their needs, so they could actually consider those areas we have most problems with locally.

  191. On a number of occasions you have said during the course of your answers that you have a problem of limited funds—I suspect this is not confined simply to you. If there is a drug which you consider is a poor product or you believe it is out of date in its effectiveness clinically, why do you not think you should be able to give local practitioners advice against implementing the NICE recommendations?
  (Dr Cunningham) Did I say that?

  192. No, what you said was that you had limited funds and it was a question of juggling priorities.
  (Dr Cunningham) This is indeed what we did before.

  193. What I am asking is whether, if NICE in effect recommended a product which you think is a poor product or that it is out of date and there are better drugs on the market or whatever—
  (Dr Cunningham) Or of less value; yes.

  194. Why do you think you should not be able to make recommendations to GPs that they do not take the NICE recommendations?
  (Dr Cunningham) That is exactly what we were doing before the latest.

  195. Exactly. But now, with the latest.
  (Dr Cunningham) That is exactly what we were doing. We would consider the guidance in our prescribing committee, which has representation from GPs, clinicians, primary care groups, hospital trusts, mental health trusts, everybody. We would consider the level of benefit we thought would be achieved for our local population and the level of benefit which would be achieved even when NICE said yes for individuals, we would consider all the other calls on our resources and how much of this we wanted implemented. One good example is statins for secondary prevention of heart attacks. We felt that this was a valid use of resources and we encouraged GPs to do it, but in terms of primary prevention we did not feel we had enough money and the six primary care groups had actively discouraged its use for that time. What we are now told is that we have to implement the guidance, which makes it a little difficult for us to advise individual clinicians not to prescribe it. We have taken advice from the lawyers on what the position of an individual clinician might be, or a manager, if they had a patient in front of them who said, "The NICE guidelines say this treatment is appropriate for me. Are you going to prescribe it?", they say no and it puts them in a rather difficult position as far as clinical governance, clinical standards are concerned and the patient.

  196. As a matter of interest, because I genuinely do not know the answer to this, what happens in the light of the changes you have just described if a drug does become out of date? Is there some way that you or the medical profession can go to NICE to point out that their advice has become outdated and is no longer relevant or maybe not the best advice? Or, can it only be done through Ministers referring another item to NICE to consider?
  (Dr Cunningham) We do already talk to NICE. We have talked to NICE about the affordability issue. We would feel able to make our views known to NICE, whether or not it was part of the formal process.
  (Dr Crayford) NICE's guidance is time limited so each piece of guidance is scheduled for review after a certain period of time depending on the technology. Usually it would be fairly contemporaneous.

Dr Taylor

  197. Since our meeting last week we have had guidance from one of the experts we had last week that there are in fact two examples where a health authority or a PCT can advise against NICE guidelines. The first one is if the authority has legitimate and well-founded reasons to think that the guidance is mistaken. The second is that the health authority or PCT may say that it has insufficient funds to accommodate NICE guidance and does not want to divert resources away from its own projects. Those are two examples that we do have.
  (Dr Crayford) In relation to legal advice, it is a side issue to the central issue of NICE, but it is expensive for the NHS. Health authorities and PCTs across the country are now independently going and consulting their lawyers about what to do with NICE guidance, how to implement it, whether to implement it, individual clinical cases. It is very expensive seeking medico-legal advice and usually the same firms of lawyers are giving the same advice to all of our different authorities. It really would be very helpful if NICE provided legal advice to the NHS about the legal implications of its guidance.

Siobhain McDonagh

  198. You still go to you solicitor to try to get a different view though.
  (Dr Crayford) I am not sure we would.

Jim Dowd

  199. Dr Walker, you said in your submission that because of the challenges NICE is facing, priority setting is a key issue for the future. Who do you think ought to be setting those priorities and who ought to be involved in considering them?
  (Dr Walker) It has to be a broad-based approach, but it has to be very inclusive and take account particularly of local priorities. This point has been raised before, that a one-size-fits-all approach is good in that it gets rid of post-code prescribing, but it can be unhelpful and it can limit flexibility locally and there needs to be some trade-off for that and local problems and local specific factors need to be taken into account in the priority setting.

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