Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 520 - 539)



  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, Minister—and I did not think it that was that difficult a question—is 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 any further.

Julia Drown

  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.

Dr Naysmith

  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 worth taking.

  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.

Siobhan McDonagh

  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 effectiveness.


  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 open there.

Dr Naysmith

  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 years ago.


  534. Perhaps you could let us know.
  (Lord Hunt of Kings Heath) I am not sure of the exact date.

Dr Naysmith

  535. It is not recently. Do you think it is working?
  (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.

Dr Taylor

  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 programme—as you are probably aware witnesses made that point—rather 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 accountability.

Mr Dowd

  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.

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