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 reportwhich
we were very grateful to you for suggesting in the first instance
because it was not something we had contemplatedI 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 fourwe will come back to thatand 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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