Examination of Witnesses (Questions 200
WEDNESDAY 23 JANUARY 2002
200. But it is a National Health Service. Why
should somebody in Inverness, for example, have different prospects
or limitations from somebody in Plymouth?
(Dr Walker) If you take the Relenza issue again, if
you want to have a drug out to people within 36 hours of them
starting their symptoms, in an urban centre like London, that
is very simple to do. There is a pharmacy on every corner and
a GP within ten minutes. In rural Northumberland it might be an
hour's drive or two hour's walk or a whole day on public transport
to get to your GP. It is not practical to have mechanisms in place
to give access to that drug to everybody in rural Northumberland.
There are differences. Also, as we heard before, patterns of disease
are different. Psychosis might be a big problem in central London,
but we have problems with respiratory disease and cancer in the
North East. There is a funding issue there about differential
funding and also how the funding is distributed once it is decided
whether it is going to be a per capita basis or a per case
basis. For example, some of the money allocated for NICE drugs
in the country is allocated to trusts as a standard uplift percentage
on the allocation every year, but different trusts will have different
amounts of need for NICE related drugs. Cancer centres may be
based in some trusts who will get the same uplift as general hospitals
with no cancer centres and yet they will have to spend a lot more
of their uplift on those NICE drugs. There are differences between
201. I can tell you psychosis is certainly a
problem in this part of central London. The other point you raise
regarding setting priorities is that "... local health authorities,
who are required to ensure the implementation of the guidance,
are unlikely to be consulted".
(Dr Walker) Yes.
202. I do not fully understand the conditionality
in that assertion.
(Dr Walker) The NICE process does allow for consultation
of health authorities but it is unlikely to be yours. At the moment
it is unlikely that every health authority is going to be consulted
about a particular issue. What I should like to see is commissioning
bodies, PCTs, in the future having the option to take part in
the process and to comment on the process and feed into the process
if it is an issue for them or they have a particular issue to
203. What problems would it avoid that you are
currently experiencing with health authorities' work. You are
seeking a virtually mandatory inclusion.
(Dr Walker) It would affect the prioritisation first
of all, the selection of products or technologies to be appraised,
but it would also take account of the difficulties in implementing
the guidance, the practical difficulties we mentioned before.
Both of those ends are not fully addressed by the process at the
204. Picking up your point and wrestling with
the issue you have all raised with us of how you determine what
you should spend a limited amount of money on in your locality,
one of the issues I put to witnesses last week was whether you
have any ideas as to how we may move in a radically different
direction involving, engaging with the local population and ensuring
that the local population in your area is consulted where there
are different views and different priorities and different experiences.
I am familiar with your area Dr Cunningham and I understand the
point you are making about 155 psychosis. Is there a way in the
process of devolving decision making, which the Government say
they are moving towards, of actually engaging with the population
on the kind of issues you wrestle with?
(Dr Cunningham) Quite a lot of us have had experience
of doing that before NICE came along. We have various ways of
consulting with the local population about where the resources
should go, including things like citizens' juries in Lewisham
and health panels and now primary groups and primary care trusts
have their own ways of consulting with the public. I think the
problem we are all facing is whether NICE guidance is absolutely
binding, whether somebody with something in the north of England
should get exactly the same treatment as somebody in the south
of England. We all recognise the problem that we want to avoid
post-code prescribing and that maybe there may be a limited list
of things which everybody has to get all round the country. Even
if we were all widely involved in the NICE consultation, if you
said respiratory disease and you said psychosis and NICE were
supposed to make sense of that, what would they do? I do not know.
It means we have to have local discretion, we have to involve
people. I know there are lots of moves from the Government to
involve people and primary care trusts are where a lot of it will
(Dr Crayford) There might be some circumstances where
NICE's guidance should be mandatory, where there are not large
national variations between the north and south of the country
or inner urban areas where post-code prescribing is irrational.
You might include beta-interferon on that but a national statement
about beta-interferon could be quite helpful. Where there are
local concentrations of disease, then that does not fit in with
local priority setting.
205. Just going back to Dr Walker's submission,
we talked about local health authorities being unlikely to be
consulted. Very importantly you said you had no right of appeal
against draft appraisal where other people do.
(Dr Walker) Yes.
206. How important do you feel that is?
(Dr Walker) There have been relatively few occasions
when it has been important. With the issue now of guidance being
mandatory effectively and more and more appraisals and this is
going to represent a larger and larger budget and a decreasing
amount of flexibility with which we have to deal with local health
problems, it becomes a bigger issue and there will be occasions
for individual health authorities wanting to contest or add information
to NICE appraisals. At the moment there is no way of doing that.
207. There is no mechanism at all at the moment
for doing that.
(Dr Walker) You can feed information back to NICE
but it is not part of the formal process.
208. Do you feel strongly about it too?
(Ms Marlow) A director of NICE at a conference I attended
was asked whether, if we felt strongly about a particular guidance,
we could appeal against it and we were told no. I feel that does
not really help in terms of ownership of the guidance.
(Dr Crayford) So in terms of improving NICE's process,
one is greater inclusiveness. Another idea is to make NICE more
financially accountable. At the moment NICE produces guidance
but it does not assume any financial responsibility for that;
we have to at health authorities. If NICE were to have a discrete
budget to work within, it would then make more sense of how it
prioritised, what sort of advice to evaluate.
209. Do you think they work too much in an ivory
tower? Is that the problem?
(Dr Crayford) Yes.
210. You are where the problems really are.
Is it giving advice which is theoretical?
(Dr Crayford) It is about how it considers the issues
that we should like to see. I should like to see NICE evaluate
the value of the nurses we need in our accident and emergency
department and it does not do that. It considers treatments which
are important, of public interest, which might not necessarily
fit with the overall prioritisation process of the NHS as a whole.
Chairman: May I thank our witnesses for a very
useful session. We are very grateful for your co-operation.