House of Commons - Health

Select Committee on Health Fifth Report

4 Why benefits are not being realised

28. The Department has recognised that it could do more to facilitate the introduction of new medical technologies into the NHS. Dr Felicity Harvey, Head of Medicines, Pharmacy and Industry Group, Department of Health, told us: "the NHS has not been good at getting new technology in."[33] In its memorandum the Department pointed out that NICE has made a contribution to improving the NHS's understanding of the clinical efficacy and cost-effectiveness of new medical technologies, but recognised that "more needs to be done to improve implementation of NICE guidance"[34] — a point that we have identified, and made recommendations about, in several of our previous inquiries.[35]

29. Witnesses highlighted evidence from other countries that have higher rates of take-up of new technologies. Mr Wilkinson told us, for example, that in Germany over 40,000 diabetes patients use insulin pumps, while in the UK the figure was less than 2,000. He believed this reflected problems of silo budgeting[36] in the UK and lack of "involvement of clinicians in the procurement process and particularly the evaluation of technologies and translation of those through everyday use."[37]

30. There are specific reasons for other countries having a superior record to the UK of implementing new technologies. Professor Sir James Underwood, President of the Royal College of Pathologists, commented that there were often fewer specialists in some countries such that there was much greater incentive and economic rationale for adopting telemedicine.[38] In Scandinavia the population is sparsely distributed and many hospitals do not have on-site services. These services, can now, be delivered and supported by telemedicine. However, some countries, with better records of implementing new medical technologies, are simply better at realising the benefits than the UK.

31. Written evidence, notably that from the Medical Technology Group, provided further information about other countries (see figure 1). Such figures need to be treated carefully, for level of expenditure in itself cannot be regarded as a measure of efficacy or effectiveness in the acquisition and use of new systems or devices. Nevertheless, the figures illustrate that the overall level of spend on medical technologies within the UK as a percentage of Gross Domestic Product is considerably lower than the European average and that of the US.


Table 1: Expenditure on medical technologies by selected countries, as a proportion of total healthcare expenditure and Gross Domestic Product.
Country	% of healthcare spent on medical technologies	% of GDP spent on medical technologies
Germany	8.6	0.92
Slovenia	7.1	0.57
France	6.5	0.62
European average	6.4	0.55
Spain	6.1	0.46
Italy	5.8	0.50
USA	5.1	0.71
UK	4.8	0.36
Data source: The Medical Technology Group, Ev 65

32. It was pointed out to us that while the NHS is seen by many as being a single organisation it is in fact a federation of more than 700 Trusts, with different and inconsistent policies and practices on new technology development, application and purchase.[39] Professor Carl May and colleagues in their submission stated: "The absence of a central policy sponsor and central funding stream for R&D, procurement, and service development is the key barrier to these new developments. It is worth contrasting this with the rapid development and delivery of mechanisms for telephone triage, advice and service delivery (NHS Direct, NHS 24)."[40] This has led to what some written and oral evidence described as a 'postcode lottery' in regard to the geographical availability of new technologies funded by PCTs: best practice is not available across the country and NICE recommendations are adopted very unevenly.[41] The diversity across NHS Trusts has resulted in incompatible and inconsistent procurement policies. It can, as Professor May , of the Centre for Health Services Research, University of Newcastle upon Tyne, argued, place "a huge obstacle to industry in negotiating its way through the procurement pathway".[42] A number of witnesses suggested it can lead to the procurement across Trusts of a wide range of devices and therapies that reflect, as Sir Christopher O'Donnell argued, 'a creeping mix' of equipment, rather than necessarily more clinically efficacious and cost-effective systems.[43] While NHS Trusts are clearly not averse to adopting technologies, they are not doing so in an integrated, rational or strategic way.

33. Even where a technology has been recommended by NICE, the large number of 'entry points' into the NHS through Trusts results in technology being evaluated locally and, thereby, subject to considerable delay and unevenness in its implementation. This can cause considerable difficulties for smaller companies. As Sir Christopher O'Donnell noted: "if every one of the Trusts who are thinking about using something decides it wants to do an evaluation, it (a) slows things down and (b) is a diabolical use of overall resources."[44]

34. This organisational and technical complexity in evaluation and procurement means that a key barrier to more effective use of medical technologies is the acquisition of discrete and often incompatible systems and devices, or ones that require quite different training and competences to use, even within the same hospital or other clinical setting. As Mr Tony Rice, Chief Executive, Tunstall Group Ltd., observed: "it is very easy to go for a number of high technology solutions that are incompatible"[45]

35. This question of incompatibility arises elsewhere too. Concern was expressed that existing digital based systems and diagnostic tools, especially used in radiology or pathology, may not be fully compatible with the NPfIT. As Professor Sir James Underwood argued:

Our concern is the interface between our laboratory information systems and NPfIT. We do have concerns about the lack of seamlessness at the interface between our laboratory systems and the National Programme.[46]

While the NPfIT may provide for the first time, as Dr Felicity Harvey noted, "a national capability" that will enable more effective use of telemedicine and telecare, its role in the wider ecology of diagnostic lab-based techniques is still to be defined.[47]

36. This lack of integration is exacerbated by the existence of silo budgeting within Trusts, and until recently relatively short-term, annualised budgets within which the commissioning process has had to operate. Recent changes towards a three-year budgetary cycle for PCTs should help to overcome this problem.

37. However, annualised budgets have left a legacy inasmuch as it has been difficult to demonstrate utility of new technologies across discrete budgetary silos. Whether extending the budgetary cycle will break this down is open to question.

38. There is often little incentive for organisations to invest in new technologies, when these may benefit others or when the investing organisations will not be reimbursed for developing new systems. Mr Dheansa, of Queen Victoria Hospital, explained that his hospital was placed at a "financial disadvantage" when it implemented its system. He informed us that QVH had spent £85,000 developing a system, but had not been reimbursed for that cost although the Trust gained "in terms of efficiency and appropriate theatre and bed utilisation".[48] Moreover, the very characteristic of some technologies, such as telecare or telemedicine, means that the trust which pays for the new technology is not necessarily the Trust which benefits from it.

39. This links to the general question of how technologies are evaluated and whether this is, unintentionally, an additional barrier to implementation. Clearly, no technology should be adopted without thorough evaluation, but how and what this means is not a simple matter. Short- and long-term benefits have to be considered. While cost-efficiency is seen as an advantage of new medical technologies, doubts have been raised about the evaluations of the true cost-effectiveness. Professor Carl May told us that cost-effectiveness is

sometimes in doubt … largely because of the poor quality of most of the economic evaluations that have been done. The truth is that we do not know whether these systems are cost effective - not that we say that they are not cost effective - and that is because the economics of the National Health Service are really some of the most extraordinarily Byzantine things in the history of humanity.[49]

He continued by saying: "the published evidence about cost-effectiveness is often of methodologically very poor quality."[50] Attempting to place a price value on improvements in a patient's quality of life provided by the use of new medical technologies further complicates any attempt to accurately evaluate cost-effectiveness. It is also difficult to accurately calculate cost-efficiencies obtained through the increase in the number of patients that can be treated in primary and secondary care through new medical technologies and the subsequent reduction in delayed discharges, reduced waiting times and reduced surgery times.[51]

40. Several witnesses suggested that there is a need for the development of methodologies that can provide for much longer-term review of the net benefits of new systems or devices. Much of the evaluation depends on clinical trials to provide evidence upon which to make a cost-benefit analysis. These can take considerable time, quite legitimately so, to determine this. Firms complain about the delays this can cause in relation to the introduction of their products, a point also made by some patient advocacy groups. Getting the balance right between thorough evaluation and the speedy introduction of new medical technologies can be difficult, and is reflected in the tension between Government policies, as Professor May noted between:

the modernisation stream which seeks to use technological innovations to move services forward very rapidly and to develop their patient centred services, services which have a degree of local participation and which cross organisational boundaries, and the policy stream that demands evidence-based practice because the production of evidence always takes a very long time if it is going to be formed in a way that will satisfy the demands of clinicians and budget holders.[52]

41. Clearly there are good professional reasons why new technologies should be adopted with caution, recognising that usefulness of new technologies depends on the circumstances. In some circumstances, rather than introducing whole new systems — such as telepathology to replace microscopy in histopathology labs — the conventional systems, here microscopes, are themselves being improved through digitisation. Whatever the specific technical features of a system, witnesses pointed out that any technology is likely to involve considerable 'behind the scenes' work to make it feasible: one has to "re-engineer the whole way you manage patients."[53] Clearly, this can act as a disincentive to the introduction of new technologies and thereby the benefits they may bring. The success of telemedicine reported in the QVH example described above (paragraph 15) depended on that Trust identifying a 'clinical champion' whose role was to help change practice and procedure in order to demonstrate benefit and enrol other members of the health team.

42. It was also pointed out to us that 'benefit' has to be related to quality assurance provisions in regard to the deployment of new technologies, especially the growing number of near-to-patient devices appearing today. Standards requirements need to reflect the risk to patients that inadequate or limited testing might create. Moreover, benefit needs to take account of the impact of new systems on carers who may be reluctant or unable to take on new and additional responsibilities.

43. The final, perhaps most important barrier that many drew attention to through both written and oral evidence was the gap between health and social care services. The Government now claims to be addressing this through pooled budgets and use of other flexibilities, but there is clearly much more to be done. In part this relates to a wider sense of the notion of budgetary 'silos' this time between Trusts and Councils and a situation where the risks and benefits are not equally shared. As Professor May told us: 'The failure of the NHS to engage with telecare systems comes back to the problem where the benefit lies. The benefit for telecare lies largely "in the field of social services because it manages often elderly, often disadvantaged, often very vulnerable people remotely."[54] Mr Rice told us:

Telecare of course is preventative and it is funded by social services and acute care is funded by the Department of Health and therefore the removal of people from the acute sector, which saves the Department of Health money, imposes an additional cost burden on social services, and until we find a way to pool those budgets … then I think the budgets and responsibilities being divided will continue to mean that we are sub-optimal in our utilisation of new technologies.[55]

33 Q 57 Back

34 Ev 32 Back

35 Health Committee, Second Report of Session 2001-02, National Institute of Clinical Excellence, HC515, paras 76, 80 and 81 and Health Committee, Second Report of Session 2004-05, The Prevention of Venous Thromboembolism in Hospitalised Patients, HC99, para 58 Back

36 Silo budgeting - the inability or unwillingness to move money between health and social care budgets at government and regional level, and in hospitals with budgetary allocation systems discouraging the movement of funds from long stay wards to day surgery care or even simply between two in-house departments. Back

37 Q 3 Back

38 Q 10 Back

39 Ev 3 Back

40 Ev 3 Back

41 Q 46 Back

42 Q 9 Back

43 Q 78 Back

44 Q 64 Back