Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 440 - 448)




  440. You may be interested to know that about a fifth of the memoranda we received came from individual members of your Appraisals Committee and other people directly connected with NICE, so we wondered whether there had been some organised attempt to offer a positive view of your work. We may be very naive people on this Committee but that suspicion crossed our minds.
  (Mr Dillon) I am very flattered that they bothered, at the most difficult time of the year for anybody to put anything together, to make the effort to do that. They may have already known that you were conducting your inquiry through your own press release. They may have known as a result of us telling them, but it was their decision, those of them that did respond, to do so and the words that they used must be their own since we have not given them any.

Jim Dowd

  441. What about the career prospects of those who did not?
  (Professor Sir Michael Rawlins) Members of the Appraisal Committee do not get paid. We do not employ them. We do not even pay them an attendance fee, only their expenses.
  (Professor Barnett) I was going to make that point. It is pretty obvious that members of the Appraisal Committee did know that this was happening and were very keen to do anything they could to make their views known. I have no idea whether they have made adverse comments or positive comments, but they were very keen to make their views known.

Mr Amess

  442. Gentlemen, what do you think of the all-Wales Medicine Strategy Group?
  (Mr Dillon) It is a good idea because it can provide a service to Wales across the full range of pharmaceuticals in a way that the Institute is not set up to do. We have heard earlier that what we get is a selection essentially of the pharmaceuticals that are introduced into the NHS. Groups like the one you have described, and there is a similar consortium being established in Scotland, have the ability to look at everything that comes into the Service and to provide some very rapid and co-ordinated information about the nature of those pharmaceuticals. A member of that group in Wales is also a member of the Institute's Appraisal Committee and at the time the National Assembly for Wales was establishing it they talked to us about its purpose. It was pretty obvious from the way they described it that there is no overlap between the functions of NICE and that group but that they complement each other.

  443. So there is no overlap and there will be a clear difference between your work and the work of this strategy group?
  (Mr Dillon) Yes.

  444. I am fascinated by your evidence because clearly, when we deliberate on your organisation, we will have to decide if we have been given some duff evidence because there seems to be a huge contradiction in the stuff that we have been sent and what you gentlemen have been telling us today, so somewhere someone is not being truthful.
  (Professor Sir Michael Rawlins) We too have read your transcripts with amazement about some of the things you have been told.

Sandra Gidley

  445. Most people, when they have heard of NICE, it is in connection with beta-interferon and the interim guidance has been rather negative, much to the disappointment of the patient groups. What then is your feeling as professionals when all of a sudden there is an announcement apparently out of the blue from the Secretary of State announcing that there will be some money to carry on treating, when your guidance seems to indicate the contrary? I am sure all the people who are getting the treatment will be delighted, but I wondered how you felt.
  (Professor Sir Michael Rawlins) We produced guidance about beta-interferon in a provisional form last August and in that provisional document we asked the Department of Health to start engaging with the manufacturers to see if beta-interferon could be acquired for patients in a manner that was to be considered cost effective because the Appraisal Committee concluded that under the present pricing—and we have no control over prices—it could not be regarded as cost effective. Those negotiations started at the same time the appraisal process continued and the final appraisal determination was released late in the autumn and there was an appeal at the end of November which I chaired. All the way through the emphasis has been that although this is not clinically and cost effective we would wish the Government to engage in discussions to make it cost effective. One of the things that happened was that we are unaware of how those negotiations are going on the detail but we do know that the model that we commissioned has been used in those discussions. We are not feeling as if we have been cast aside or ignored. In fact, we are pleased that the Government has taken our suggestion in hand.

  Sandra Gidley: Does this not have interesting implications for drugs budgets if you recommend this in future?

Dr Naysmith

  446. Can I just add something before you answer that? Did you say that it was not clinically and not cost effective?
  (Professor Sir Michael Rawlins) No. It is clinically effective but it is not cost effective. I beg your pardon if I misled you.

Sandra Gidley

  447. It does have some interesting implications for future negotiations with the drug companies, I suspect. If I could come back to something that has been touched on but we have not really got on the record from you, you mentioned that you have been accused of setting a level for the quality adjusted life years and it is reckoned to be around £30,000 unless there is overwhelming evidence that it is over that. It is a very nebulous concept in lots of ways. The example you gave about lung cancer was very straightforward and clear but with other drugs and other conditions it is not so clear. Would you comment on what guidance you have been given or by whom on the use of QALYs and how can you improve that in future so that that process is more transparent?
  (Professor Sir Michael Rawlins) In essence the health economic evaluations have been very much based on the advice of health economists, and one is of course the Vice Chairman of the Institute. I think however it would be more appropriate if David Barnett described to you how the Appraisal Committee uses the health economic data.
  (Professor Barnett) There are two components to your question. Perhaps I may just address the first part which is the issue about a nebulous threshold. The Appraisal Committee does not consider the threshold and has not been given instructions about a threshold and has not discussed a threshold per se at all. If I might just give you an example as to the concern that the Appraisal Committee has about the range of health economic evaluations that it gets about a particular technology, the example which I and the Committee were faced with a year ago last October, when the first appraisal of beta-interferons had been concluded, was that the published and unpublished estimates of cost effectiveness of the beta-interferons internationally range from £10,000 per QALY to three million dollars per QALY. I am just an ordinary chap and I am not a health economist; I practice medicine. Even I thought this was just not acceptable. There was a problem here and we needed to have better evidence, more data and a more refined answer to this. Irrespective of some nebulous threshold it did not match up at all. That is the first situation. The second is the issue about QALYs. QALYs are not the answer, definitely not. They are, however, the only thing we presently have which is internationally recognised and gives us a handle on comparisons across technologies, across disease states and across individuals and age groups. They are not the final answer and I think the health economy world understands that. I believe that NICE in its present format should catalyse the debate about how to do this better in the future, but I am afraid we are stuck with what we have. Therefore we do our best with it. It is pretty obvious from some of the appraisal examinations that it is not possible to represent a QALY which is why we use cost per life again as some surrogate for that. It is not good enough but it is the best we have got at the moment.

Jim Dowd

  448. Just on that very last point, I first came across QALYs when I was on the health authority in North Suffolk back in the 1980s. Everybody accepted that they were a good idea but the problem with them was that nobody could decide on a uniform definition of what should be included, how information could be collected. Are you saying that we have now resolved that?

  (Professor Barnett) Oh no. I do not think we have resolved it at all, far from it. What we have, however, is a movement towards wanting to resolve it and a movement towards the Institute hopefully being one component to catalyse that debate internationally. We have our own impressions of what we should be doing and I believe that we will move in that direction.

  Chairman: If there are no further questions, can I thank you for a very interesting session. We are very grateful to you.

previous page contents next page

House of Commons home page Parliament home page House of Lords home page search page enquiries index

© Parliamentary copyright 2002
Prepared 8 July 2002