Examination of Witnesses (Questions 520
WEDNESDAY 6 MARCH 2002
HEATH OBE AND
520. How, by cutting services?
(Lord Hunt of Kings Heath) You seem to be suggesting
that an increase in drugs is not an increase in service, of course
it is an increase in service.
521. What I mean by services is the number of
operations carried out, the number of times a consultant sees
patients in out-patient appointments, the number of hospital beds
that are used. All I am asking, Ministerand I did not think
it that was that difficult a questionis how do you anticipate
this deficit being eliminated?
(Lord Hunt of Kings Heath) At the danger of repeating
myself again, it is a matter for each NHS organisation, they have
to juggle the figures, they have to predict as effectively as
they can the likely cost pressures. They will have to shift resources.
This is the normal business of the NHS.
522. So the answer is to cut services?
(Lord Hunt of Kings Heath) I do not think you should
take that at all. What I said is it is a matter for every local
NHS organisation. You are wrong to suggest, as you continually
imply, that somehow if you are increasing drug costs that that
is in itself an increase in services, because it is not.
Mr Burns: I have not suggested that at all once,
Minister. I have never said that at all. I can understand we are
not going to get an answer.
Chairman: I do not think you are going to get
523. I want to ask about implementation and
to take up a point you said that you think most of the NHS has
implemented NICE's guidance, perhaps not all, and the ABPI, which
obviously has an interest in this, did do a survey of prescribing
data and they thought that the uptake in terms of the prescription
of NICE approved drugs was only about one third of the total and
that the increase in uptake in terms of prescribing is only a
third of the total that NICE estimated. Of course a number of
patients would have been prescribed before the NICE guidelines
came out as well. In your view, have you any estimate on how to
prescribe it and how that balance against what NICE estimated?
(Lord Hunt of Kings Heath) We do. I think we have
given you some examples, for instance with the anti-obesity drug,
where expenditure on Orlistat increased from half a million to
two million after the NICE appraisal guidance was published. It
is the same sort of figures roughly in terms of the proportions
for drug groups outside this. It is quite difficult to actually
get these figures exact for two reasons, one is that if you look
at NICE guidance it does not often say yes or no, what it says
is that under these prescribed circumstances this drug should
be made available. Secondly, we are beginning to see a trend whereby
once a particular drug is referred to NICE and the Health Service
observes that they may think it is likely this drug might be approved
by NICE and that may have an impact on their decisions at local
levels. It is quite hard, in fact, to come up with precise figures.
The general feeling we have is that NICE guidance is taken very
seriously by the NHS. We ask health authorities on a quarterly
monitoring basis to say to us whether NICE guidance is being implemented
or not, so we check on that. We are going to do more checks. We
are getting more information available about hospital prescribing
rates, which will be another way in which we can check this out
in future. The guidance itself, the directions that we are now
issuing to the NHS themselves will have a powerful impact. Finally,
we have asked the Commission for Health Improvement, when they
do their regular reviews of the NHS organisations to check that
out as well. We have gone as far as we can to make sure that the
guidance is implemented.
524. Minister, making NICE guidance mandatory,
the point has been put to us both by pharmaceutical firms and
health authorities that once you do that for one particular treatment
it would result in apathy in the sense that other treatments that
have not yet been tested or assayed by NICE will be less favoured.
Do you have any views on that?
(Lord Hunt of Kings Heath) There is always a balance.
One of the arguments is about whether you look at one drug or
you look at a class of drugs. I think we have learned through
experience that you can move away from very narrow remits in terms
of asking to appraise one drug to get a more balanced view by
making comparisons with a class of drugs. Obviously if you do
a class of drugs that takes more time and that will limit the
number of appraisals that we can undertake. Certainly it is a
factor that we are now very carefully considering in terms of
future work programmes for NICE. It is certainly a point well
525. It is something that has been put to you
and something you have set?
(Lord Hunt of Kings Heath) Indeed so, yes.
526. Moving slightly away from that but returning
to what you were saying earlier in your answers to this set of
questions, it brings us to the local/national argument which has
always been there in the National Health Service and carries on
apace all the time. One of the things you said was that the National
Health Service locally would be able to feed back and suggest
things that needed to be appraised by NICE. We are bringing in
local government committees in the form of scrutiny committees
to look at performance locally, which is a totally different area,
but nevertheless do you think they will start to suggest things
that ought to be appraised by NICE, particular treatments and
particular ways of doing things locally that may not have occurred
to people nationally?
(Lord Hunt of Kings Heath) First of all, I think the
overview scrutiny committees are going to play a really important
role at local level in ensuring that the Health Service is held
accountable at local level. I suspect there is going to be some
pretty rigorous debate between the local authority scrutiny committee
and the NHS. If as part of that process ideas come up which might
be relevant to the kind of matters we are discussing, of course
we are very open to considering that. Although there is going
to be rigorous discussion, I want out of it there to be much closer
co-operation in future between the NHS and local government. It
may well be an area we want to consider. There is certainly no
bar at all on overview scrutiny committees from making suggestions
for the work programme of NICE, none at all.
527. It might also raise the prospect that you
have got the poor old health authority or the primary care trust
caught in the middle where the Government is giving guidance,
"You have got to implement government guidance locally"
and the scrutiny committees of the local authority saying locally,
"We do not think that is a good idea, we think you should
be doing something else." In that sort of situation what
does the trust do?
(Lord Hunt of Kings Heath) It has certainly got to
carry out the directions that we have issued in relation to implementation
of NICE guidance. That is a given. We are absolutely determined
that NICE guidance is implemented in full. More generally, of
course, the overview scrutiny committees will put new pressures
on the Health Service but I think that is absolutely right. If
one looks at the NHS, one of its big problems in the past has
been the lack of engagement with local government and the democratic
process at a local level. That has led to some of the problems
over some of the decisions it has taken and a lack of support
perhaps for major changes in services. Of course, the overview
scrutiny committees will put the pressure on, but I think the
outcome will be a much better relationship between the Health
Service and local government and that will produce better patients
and better integration of services. I think it is well worth doing.
528. Is it appropriate for one body to assess
both clinical and cost effectiveness when these are very different
disciplines which may require very different types of expertise?
(Lord Hunt of Kings Heath) I do. In my view it is
very important that the two come together because as far as the
National Health Service is concerned these are the key questions
that need answering. It is one of the reasons that we have run
into the problem of postcode prescribing. It is one of the reasons
that we have run into problems with inconsistency over the provision
of services between different parts of the country. Of course
clinical effectiveness is important but we also need to know that
a particular clinical intervention is cost effective and that
it is worth the NHS spending money in that area. I believe it
is better to combine that so that you get a rounded judgment from
NICE, which we are seeking to come through. The issue then comes
down to affordability. That is different. I accept that is an
issue which falls to ministers to decide, but I believe that the
quality of the advice we receive from NICE is much better if it
is rounded and involves both cost effectiveness and scientific
529. On the assessment process, we have had
a number of pieces of evidence indicating that there appear to
be occasions when there is some reluctance by the pharmaceutical
industry to fully furnish details about their products in the
assessment process. What are the reasons for the distinctions
between NICE in relation to assessment and, for example, the way
in which the Medicines Control Agency operates where pharmaceutical
companies are required by law to furnish all information?
(Lord Hunt of Kings Heath) I suppose there is a difference
in the sense that the MCA and the Commission on Safety of Medicines
are legal processes which will lead to decisions about whether
a drug can be made available or not and be given a licence and
that is obviously the reason for the distinction. We have not
had evidence brought to us that information is being deliberately
withheld in order to try and influence a favourable NICE decision.
530. You are aware it has been put to the Committee?
(Lord Hunt of Kings Heath) I am aware that there has
been some discussion in Committee. Obviously if there were substantive
evidence we would consider it and decide what action needs to
be taken. As I say, we have not had any substantive evidence brought
before us. I would obviously want to encourage the drug industries
to be as open as possible. We know that it has become the practice
with one or two companies to always publish the details of clinical
trials and also to guarantee that the results of those will be
published whether the results are favourable or not. That seems
to me good practice that we want to encourage. As I have said,
if there is specific evidence that shows that information is being
deliberately withheld for no good reason then we would have a
look at that and see whether we need to take any action.
531. What would the options be? Have you a statutory
requirement of some kind?
(Lord Hunt of Kings Heath) That is one of the options.
Another option would be discussion and agreement with ABPI as
to the way forward. There are a number of options that would be
532. One of the other things that has been put
to us by pharmaceutical companies particularly, but also by patients,
is the existence of NICE "blight" where when a drug
is being considered then it inhibits its use in all sorts of things.
What is your view on that?
(Lord Hunt of Kings Heath) We have issued a circular
to the NHS which essentially says that you cannot use the fact
that a particular drug is being reviewed by NICE as a reason for
a blanket refusal to fund that during the interregnum period.
Essentially we are saying that decisions must be made locally
by individual parts of the Health Service on the basis of the
evidence that is available to them. If there are cases where Members
of Parliament come across instances where a blanket decision has
been made by, say, a health authority not to fund a particular
treatment because NICE is considering it, we will take that up
with the individual health authority.
533. When did that circular go out?
(Lord Hunt of Kings Heath) I think it is two or three
534. Perhaps you could let us know.
(Lord Hunt of Kings Heath) I am not sure of the exact
535. It is not recently. Do you think it is
(Lord Hunt of Kings Heath) Yes, but as I say, again
sometimes the Health Service does not, surprisingly, implement
every dot of every guidance we give. I think it was 1999 that
the Circular was issued.
536. The problem was still being raised with
us a couple of weeks ago.
(Lord Hunt of Kings Heath) I repeat this offer: if
people can provide for me specific evidence that blanket refusals
are being given, we will go to the NHS authority concerned and
say they cannot do that. We are absolutely clear on that.
537. I shall be writing to you tomorrow. We
heard on a television programme, which I am absolutely sure is
correct, that herceptin is given in most of Birmingham and is
not given in South Staffordshire and Worcestershire because they
will not allow it.
(Lord Hunt of Kings Heath) Whilst I would always accept
that Birmingham's health services are first rate, it really depends
on the reasons that may be given. The question for us is has a
local health authority gone through a proper process of considering
whether a particular drug should be made available. What is not
acceptable is simply for a health authority to say, "No,
it is not being made available because NICE is considering it."
Perhaps we can send you the circular so that you can see the terms.
I will particularly send one to Dr Taylor on that.
Dr Taylor: I will still be writing to you.
538. You cannot write any more! It is worth
making the point though, he broke his arm in America and chose
to come back to the NHS to have it treated. Can I raise one other
point about the evidence that we received, I think it is fair
to say that a lot of our evidence pointed to support for NICE
actually determining its own work programmeas you are probably
aware witnesses made that pointrather than being determined
in the current way. What are your views on this?
(Lord Hunt of Kings Heath) I have given a lot of thought
to it but do not agree with it. It is very right NICE should be
independent once it has been give its work programme. Ministers
in the end decide the overall strategy and the direction for the
National Health Service. We made it clear that appraisals and
guidelines will be very much focussed round the priorities we
set for the NHS. In the end it is for Ministers to make those
decisions and be accountable for those decisions. I will also
make the point, we have just been discussing implementation, the
fact is that we have now issued directions to the NHS to make
sure they fund those decisions. Given the strength of that central
direction I would not believe it to be right to actually then
place those kind of decisions in the hands of an independent organisation,
which is what you would be doing. At the end of the day ministers
must direct the strategy for the NHS and be held accountable.
Deciding NICE's work programmes to me falls in the remit of ministerial
539. The privatisation of spending in the Health
Service is an ever present pressure and it is difficult to grasp.
Is NICE's concentration on, perhaps, marginal treatment, which
benefits only a relatively small number of people, confusing that
issue insofar as it is not looking broadly enough?
(Lord Hunt of Kings Heath) I do not really think so.
If I were asked what I thought was one of the big problems of
the NHS that we inherited it is inconsistency between one part
of the country and another. Why should the availability of drugs
in Birmingham be different from Solihull or even Worcester, dare
I say it. There is no justification in a National Service, where
ministers are accountable to Parliament for its running. For me
one of our key priorities is dealing with that priority, that
leads to the establishment of NICE and the setting of directions,
which does tell NHS authorities what we expect them to do. I think
that is eminently justified. I also think that it is not either/or,
as we have just discussed. NHS authorities are having to make
difficult judgments all of the time about where they spend their
resources. The amount of resources needed to be spent on NICE
guidance is very small compared to the overall expenditure of
the NHS. I think it is worth it to get this greater consistency.
I also have to say looking at the appraisals that have been undertaken
so far I doubt whether many of the patients who are now going
to benefit from those drugs would describe those as marginal to
the benefit that they think they were getting. It is pretty important
stuff and core stuff for the NHS to deal with.