Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 500 - 519)



Julia Drown

  500. One of the intentions as much as anything is the wish to have a National Health Service and national guidelines on the one side and then to have on the other side people locally owning plans and policies. NICE is only going to be successful if that is achieved. At the moment we hear stories of individual clinicians saying, "Oh, well, NICE has recommended this but I do not agree with it", so they are recommending a different treatment for the patient and that is obviously undermining NICE and making patients very confused. In your view how successful has NICE been in trying to establish that local ownership and do you have any other ways of trying to further that?
  (Lord Hunt of Kings Heath) I think you have raised a very important point. I make no apologies for the fact that some of the actions we are taking in relation to NICE and the national service frameworks on the question of health improvement are trying to get national consistency through the NHS. I think that is entirely justifiable. Anyone who has worked within the NHS will know that that will only be successful provided you also give enough space to people locally to manage the Health Service and that they do feel some ownership. I agree that we need to do more to give the NHS more input into the whole NICE processes. This was a matter that I discussed with NICE at our last meeting and they have said that they have taken that on board. That is one of the reasons why on the appraisal committee for a particular appraisal there will be two health authority representatives to give a considered NHS input. Equally, I want to encourage the NHS themselves to be much more proactive in suggesting guidelines or appraisals for NICE to consider. They have a lot of experience in the front line about particular treatments or drugs where there may be uncertainty or controversy where definitive advice from NICE would be welcome. At the moment we have not been too successful in getting the NHS to come forward with many ideas. I would regard that as a key challenge both for us as a department and for NICE to get much more NHS input. When I say NHS of course I mean the NHS organisation but also individual clinicians as well.

  501. What about the circumstances in which NICE looks at two drugs, A and B, and they recommend drug A? What do you do with the clinician that continues to want to prescribe drug B and tells their patients that that is the best thing?
  (Lord Hunt of Kings Heath) The position on that is that of course ultimately individual clinicians must make their own individual decisions but, through the clinical governance arrangements that are in place in every organisation, they would of course need to explain and justify why they have done that. Obviously my expectation is that NICE guidance will be credible, that the profession will see it as credible, and will see the merit in following the advice that they give.

  502. Will there be a way for them to continue the debate with NICE if they wanted to?
  (Lord Hunt of Kings Heath) Yes, and again, just as we have talked about the importance of patient groups and the NHS being involved in discussions with NICE and the other organisations, the professions themselves have a vital role to play. It is interesting that in relation to the clinical guidelines the nursing and medical Royal colleges have a very important role to play in collaboration with NICE on those guidelines, so yes, very much so.

  503. You focused there on clinicians. When we had the health authority witnesses coming to the Committee, there was a real concern that NICE's estimations of cost effectiveness are not the same as their own and do not match their budgetary decisions that they are having to make. What is your view on that?
  (Lord Hunt of Kings Heath) There are two things there. First of all, why are we here? We have postcode prescribing which many of us find utterly unacceptable. Whilst I am very committed to giving as much freedom as we can to the NHS locally, the fact is that it is those very NHS organisations who presided over a very inconsistent practice, so I am afraid I am not that sympathetic to that complaint coming from the NHS. Nor am I sympathetic to the suggestion that somehow or other NICE guidance distorts NHS priorities. I tell you that getting NICE guidance implemented in the NHS is one of the Minister's key priorities because we want to end postcode prescribing; we want to see much greater consistency. The fact is that alongside national service frameworks we are focusing on what we regard as the key clinical priority areas, so I am not at all sympathetic of that viewpoint.

  504. Two questions arise out of that. If that is the case why, when NICE first came in was there not guidance issued which was issued recently, the directive saying that all NICE guidance should be mandatory now? Also, as with beta interferon, the guidance came out saying that it was effective for some patients but in cost effective terms it was not persuasive. Does that not of necessity mean that NICE is looking at some treatments that might be at the margins of cost effectiveness which clearly, when you take it down to a health authority level, might mean that health authorities' balance of cost effectiveness would mean that it would be different from the national priorities?
  (Lord Hunt of Kings Heath) There are two points to be made about that. The first is that in terms of the resources that are available to the NHS we are in a position where the NHS, as you know, is receiving record increases in its resources.

  505. You mean there are not pressures there all the time?
  (Lord Hunt of Kings Heath) We all understand the pressures and of course we are now going through the annual agonies of the SAFF round where everyone shouts to the hilltops about their problems and then coming to agreement. You well know that process which takes place every year the NHS has ever existed and we are in that at the moment. The fact is, however, that in the additional resources that the NHS is receiving they have enough money to be able to fund the impact of NICE guidance as well as the priorities that we have established. In terms of the NHS, of course I understand the cost pressures, but I do not believe that anything that we have done detracts from the affordability of the NICE decisions at local level. Of course, if you want to end postcode prescribing you are constraining the ability of people at local level. You are saying, "In this area we are insisting that you fund it", but I think that is right because that is the only way in the end we will end postcode prescribing.

  506. Would you just answer my other question about why not mandatory from the beginning?
  (Lord Hunt of Kings Heath) Why we did not issue directions to the NHS to fund guidance?

  507. Yes.
  (Lord Hunt of Kings Heath) We obviously expected that the NHS would implement NICE guidance. By and large I think they have, although we have heard concerns from various people that they have not. My own view—it is the Government's view—is that the whole integrity of the NICE process depends on their guidance being implemented. We all know the history of the NHS which is that there were good reports being issued which were not implemented. There was no point in our establishing NICE unless we could be assured that what it advised the NHS to do actually happened. To make doubly sure we issued these directions early this year.

Dr Taylor

  508. We know the Government is putting more money into the NHS but I would suspect that every health authority would disagree with what you say, that they have been given enough money to do their priorities and to implement NICE guidelines. The trusts that have talked to us have given us stark examples of either doing something recommended by NICE or having four extra casualty nurses. I would think very strongly that every trust and health authority would disagree with that statement.
  (Lord Hunt of Kings Heath) I do not think it should be an either/or position, should it, because the money that we are putting into the Health Service—what are we talking about: 6.25 per cent extra reel-terms growth in the current financial year—is there to fund the impact of NICE guidance, yes, but also to develop the service. Of course every individual organisation is going to have to make difficult choices about where they spend the additional money but I do not accept that by making it a requirement that NICE judgements are financed somehow or other you are debilitating the public in a particular vicinity because you are having to curtail services. I do not accept that. I believe that the implementation of NICE guidance is to the benefit of the public and I believe that overall the financial settlement is sufficient to allow the NHS to develop its capacity. Of course all of us who have been involved in the Health Service will know that you will never ever get enough money to do everything that you want to do. This does not detract from the fact that at local level people have to make difficult decisions. Of course they have to make difficult decisions. But you come back to the original principle: why are we here? We are here because we want greater consistency; we want to make sure that the most robust evidence that is available translates itself into local decisions. That is why we set up NICE and that is why we are in effect instructing the Health Service to finance NICE guidance.

  509. This is why I think NICE is fairly badly flawed right from the beginning, because it focuses the desire for money on the things that it examines and the things that it does not examine, perhaps, get pushed down the list, and these could be of equal importance or greater importance.
  (Lord Hunt of Kings Heath) You have to put it in perspective. We reckon the gross costs over the last 12 months—

  510. I am not trying to say there will be enough money for everything.
  (Lord Hunt of Kings Heath) The gross costs of the drugs recommended by NICE over the last 12 months is roughly round £300 million. That is a substantial amount of money, but compared to the overall money spent on the NHS, I would suggest, that is a fairly small element. I would not accept that the impact of the NHS having to fund NICE guidance is so great that it is having a distorting effect on local priorities. It is one of the cost pressures that they have to face and it is something that we take into account when we allocate money to the National Health Service and negotiate with the Treasury how much money they should have.

Dr Naysmith

  511. Do you have contingency plans if it does happen, if that expense is too great?
  (Lord Hunt of Kings Heath) I hope that that will not arise. Obviously it is not a risk as of yet. I suppose in a hypothetical way you reach a situation where a particular appraisal was likely to lead to huge expenditure in the NHS, which it was felt could not be afforded in any one financial year. The government would obviously have the option of issuing modified directions to the NHS which might say that has to be phased in. If it were to do that my colleague John Denham, the Minister responsible for NICE when it was established, has already said that if that were to happen then the Government would make a statement round it. I hope that does not arise.

Mr Burns

  512. I have a question, very briefly, on this question of costs. I can understand what the Minister is getting at. Did you notice about three weeks ago in our House one of your ministerial colleagues published a report of health authority by health authority on, in most cases, the drugs deficit which, I think, if you tot it up—there were a few that had not gone into deficit—there was an overspend of about £300 million this year. How is that going to be recouped? Will services be cut to recoup it or will the government make additional resources available to help them get over these deficits?
  (Lord Hunt of Kings Heath) No, the Health Service will have to find the money from its own resources, and that is quite proper, particularly out of the amount of money we are putting in.

  513. How?
  (Lord Hunt of Kings Heath) It is a cost pressure that the NHS will have to face up to, like other pressures as well.

  514. I presume fairly soon because the financial year ends in three weeks!
  (Lord Hunt of Kings Heath) Let me make two points, first of all we are talking about £5 billion spent on drugs in the NHS.
  (Mr McKeon) It was rather more than that, £7 billion.

  515. £300 million is quite a lot if it has to be found by the end of the financial year, I was just asking how the government is going to find the money to meet this deficit?
  (Lord Hunt of Kings Heath) We would expect the NHS to meet any additional cost for drugs from its existing resources.

  516. How, by cutting the service?
  (Lord Hunt of Kings Heath) In the normal business of the NHS, juggling competing pressures they will have to find ways in which to do so.

  517. Does that mean cutting services, because they have three weeks to the end of the financial year?
  (Lord Hunt of Kings Heath) The issue of cutting services—you are almost suggesting that the increase in drug costs is per se bad and that has a negative impact on services.

  518. I have not said anything at all. I asked how the money is going to be found?
  (Lord Hunt of Kings Heath) I do not take that view. That is why we have prescribing advisers, they are very helpful in doing that. Ultimately if drugs are effective then we should not see a rise in the drug bill as necessarily per se a bad thing. All I am saying to you is that the NHS has to deal with cost pressures all of the time. Events are always occurring, you can have problems with the increase in the number of people coming from emergency admissions, all of those are pressures, and the NHS has to handle that.

  Mr Burns: Can I deduct from that answer, Minister, you do not know how this money is going to be found?

  Siobhain McDonagh: How do you know what every health authority is going to do on an individual basis?

Mr Burns

  519. I am waiting for the minister to answer.
  (Lord Hunt of Kings Heath) I just told you, with the greatest respect, Mr Burns, that I would expect every local NHS organisation to contain its cost pressures.

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