Select Committee on Health Appendices to the Minutes of Evidence


Memorandum by Cancer Research Campaign (NC 115)

  Thank you for the opportunity to submit to the first inquiry into the progress of NICE in respect of the key goals outlined in your press notice. The Cancer Research Campaign, shortly to become Cancer Research (UK) with the merger to the Imperial Cancer Research Fund, has had a substantial input to NICE indirectly through its Clinical Directors and a direct submission during the assessment of the Campaign's brain cancer drug Temozolomide (Temodol). Technologies within the field of oncology have made up a substantial portion of the assessments carried out by NICE to date. Our combined submission reflects the assessments of those Clinical Directors and NCRI Clinical Study Group Chairmen who were able and willing to reply over the Christmas holidays. In order to keep within the remit of the Committee we have addressed each of the key goals envisaged in "A First Class Service".

Q.  Is NICE providing clear and credible guidance?

  The concensus is that the guidance has been clear, however, there are issues in relation to credibility where a lack of expertise in oncology has led to a perception that the appraisals lack specialist "clinical common sense". This problem is also believed to have contributed to certain idiosyncrasies in some determinations, for instance, why "approve" Fludarabine and not Rituximab for lymphoma when the qualitative evidence is very similar?

  Other issues have also arisen which reflect on the credibility of the guidance. It is often difficult to see how decisions are made when no explicit criteria are set out against which decisions are made, for instance how much weight is attached during deliberations to the various sources of information from trials through to ad hoc patient experience?

Q.  Has it ended confusion by providing a single national focus?

  Again the consensus is that it has ended confusion in that there is now a single national focus for decision making, however, again there have been instances where Department of Health decisions have preceded the deliberations of NICE, eg Imatinib (Glivec).

Q.  Have the guidance's been locally owned and acted on in an appropriate manner?

  There have been considerable local variations in the way in which NICE guidelines have been interpreted, particularly with regard to funding (after the failure to ring-fence 2001-02 National Cancer Plan monies). The comment has also been made that guidance issued as central edict cannot, by definition, ``locally owned'' since it is acted upon out of compulsion. However, the major issue relates to the lack of extra monies available to the Trusts to enable implementation of the technology appraisals.

Q.  Has NICE chosen the right technologies to assess?

  It is recognised that the choice of the right technologies to assess is very difficult and by necessity NICE has appraised a number of new anti-cancer drugs. A number of issues though have arisen. Firstly, it is unclear how technologies are chosen, in particular it has been notable that appraisals of capital equipment and procedures (therapeutic and diagnostic) have not been as prolific as drugs. It is clear that NICE need a much larger task force to increase capacity and tackle the other issue which has been the rather slow pace at which the appraisals are done. There is also a serious concern about the time lag between granting a product licence and the earliest NICE appraisal, especially when an agent demonstrates substantial efficacy in a disease with few therapeutic options, eg Imatinib in the treatment of Gastro-Intestinal Stromal Tumours (GIST).

Q.  Is the NICE committee perceived to be independent?

  The perceptions about the independence of NICE are mixed. The major point raised with respect to a perceived lack of independence is the suggestion of an excessive influence of the Department of Health due to NICE's emphasis on costs rather than efficacy. The perception is that NICE have to keep the impact of total cost of implementing any one technology a very high priority in their deliberations.

  Thank you for your consideration. NICE has been an important initiative and, in conclusion the recommendations we would like to make are:

    —  The secondment of clinical cancer experts onto NICE when appraising the relevant technologies.

    —  The publication of explicit thresholds for efficacy and cost, as well as a transparent system for judging the submitted data.

    —  Parallel appraisal with the Competent Authority of technologies which address urgent clinical needs.

    —  Dedicated extra funding to Trusts to follow the final appraisal determinations.

January 2002

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