Select Committee on Health Minutes of Evidence


Examination of Witnesses (Questions 900 - 910)

THURSDAY 20 JANUARY 2005

PROFESSOR SIR MICHAEL RAWLINS AND MR ANDREW DILLON CBE

  Q900  Dr Taylor: I think one of our ideas and hopes was that this might give you better access to some of the commercially confidential details which you did not have. Has that happened?

  Professor Sir Michael Rawlins: Not to that extent. That is not necessarily the duty of the MHRA, they are circumscribed by the European route. I have to say it was to the eternal credit of the MHRA that Tim Kendall and his colleagues discovered the basis of the SSRI problem in children because they published the data on the website. That is something which would never have happened when I was chairman, you were not allowed to think about such things. Those sorts of things have been very important in helping us. I am sure it is the intention of the MHRA to carry that forward.

  Q901  Dr Taylor: After our inquiry you got the WHO to do a report. One thing it advised was to make public the basis of any of the advice you published. Have you been doing that more?

  Professor Sir Michael Rawlins: We have been discussing with the pharmaceutical industry in relation to commercial and confidential data. Andrew will comment on that. The WHO did admit they wanted to use us as stalking horse for getting more clinical trials out into the open.

  Mr Dillon: We never had a problem in being able to publish enough information to justify, we believe, the decisions of taking the recommendations we made. Sometimes we had to negotiate hard with individual companies to obtain agreement on the release of particular pieces of data to allow that to happen, but we have always felt confident that we have been able to say enough. Following our last appearance before the Committee, the ABPI and NICE sat down and reached agreement on formalising what up until then had been informal episodic arrangements with individual companies in the form of a recommendation to all the associations' members. That is now in a protocol which is operated both by NICE and the industry.

  Q902  Dr Taylor: My memory is before the last inquiry we did get a lot of comments from people who felt you were working in a slightly obscure, less than open way. Do you think you have changed that?

  Professor Sir Michael Rawlins: I think they were under a misapprehension and after the WHO report—which we were very grateful to you for suggesting in the first instance because it was not something we had contemplated—I think they recognised that it was more transparent than any other process in the world in that sense.

  Q903  Dr Taylor: Can we turn to implementation. I am sure this is a fairly sore issue for most of us because certainly I get constituents writing to say: "This has been passed by NICE and I cannot have it, why not?". Have you any idea of the rate of implementation?

  Professor Sir Michael Rawlins: The best information we have is probably from a survey we commissioned 15 months ago by Abacus who looked at 28 pieces of guidance which had been produced in the previous two or three years. They estimated there had been full uptake of 12 of those 28. There had been over-implementation of four—we will come back to that—and under-implementation of another 12. It was not a catastrophe but it was not nearly as good as it ought to be and in fact, we are setting up an implementation programme within NICE. The over-implementation was sort of curious. For example, we did an appraisal of metal on metal hips, instead of having the whole thing put in you can just put a bit of metal on the two surfaces. We estimated there were about 5,000 people a year who would warrant this type of thing, particularly young people. In fact, within a year 14,000 had been done. We may have got the wrong estimate, the epidemiological data might not have been that reliable. That is what I mean by over-implementation.

  Dr Naysmith: There could be other explanations for it.

  Q904  Dr Taylor: Were you able to tie down the implementation and the degree of it to any particular areas of the country, any strategic health authorities or specific PCTs?

  Professor Sir Michael Rawlins: We have not done that but we have some data on it.

  Mr Dillon: Yes, particularly with cancer drugs. We have data which shows the uptake of specific drugs, probably about eight or nine, by Cancer Network, which is probably the right geographical unit given the nature of those drugs. That shows the distribution before and the abuse of those drugs against an assumed appropriate target, given the nature and size of the population for each cancer network, both before NICE guidance was issued and after NICE guidance was issued.

  Q905  Dr Taylor: Have you been able to relate that to whether the particular area is struggling with its finances or not?

  Mr Dillon: Most of the NHS struggles with its finances most of the time.

  Q906  Dr Taylor: The Government tries to deny this.

  Mr Dillon: It is all relative.

  Q907  Chairman: It is a good job Mr Burns has left.

  Mr Dillon: Of course all organisations struggle with their finances in order to make the best use of available resources. What is interesting about the data is it shows that high performing cancer networks and strategic health authorities, where other data is analysed in that way, tend to improve their performance. Generally, all parts of the NHS improve after NICE guidance has been issued. The rate of improvement is greater in those that were already doing well, which is an interesting phenomenon.

  Q908  Dr Taylor: Can you tell us where we can find the details of this data?

  Mr Dillon: On the NICE website.

  Q909  Dr Taylor: Again, when we were doing the previous inquiry we did have some worries that perhaps the selection of drugs for NICE guidelines did have an impact on other services and got preferential prescribing for these things against things which are time-honored and terribly useful, but did not have NICE guidelines. Have you had any further comments or thoughts on that?

  Mr Dillon: When we go, as we do regularly, around the NHS and ask questions about the impact of NICE guidance, it is still an issue which comes up, but the reality is with or without the NICE guidance these interventions are going to be available to the NHS. Decisions are going to have to be taken relative to other desirable improvements in the service and funding interventions and practices which have been available for some time. The benefit of NICE guidance is that at least it informs those decisions in a way which quite often in the past simply did not happen. It reduces the variation in the way those difficulties are handled. In the end, the NHS and all the healthcare systems will always be presented in a way with more than they can consume, therefore, there is a need to make decisions, critical things to make sure they are evidence based.

  Q910  Dr Taylor: Is 100% implementation of your guidelines possible or desirable?

  Mr Dillon: In the end, probably not because they are guidelines and not every single patient presenting with a particular condition will benefit necessarily in the way we have described, so no it is not likely that is the case.

  Professor Sir Michael Rawlins: We estimated that about 80% of patients would fit into a conventional guideline and, for all sorts of very good reasons, 20% would not.

  Dr Taylor: I am very glad you said that because one gets the feeling that some people feel it has got to be 100%. I am grateful for that.

  Chairman: Thank you very much, gentlemen. We are grateful for your help.







 
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