Rationing
234. The question of the threshold used by NICE is
key to any discussion of healthcare rationing. Ensuring that guidance
is affordable to purchasers is vital if NICE is successfully to
perform its vital role of helping to ensure that the NHS's budget
is spent as cost-effectively as possible. The resources of the
NHS are limited, and the funding increases of the last few years
will not be repeated in 2008. The cost of new health technologies,
including medical treatments and diagnostic and surgical procedures,
is rising. At the same time, the population of the UK is ageing
and with age comes increasing healthcare needs. As Professor Rawlins
told us, "every single developed country has got the same
problem".[225]
Demand outstrips resources; as a result rationing occurs in all
healthcare systems.[226]
Several witnesses highlighted the consequent need for a true public
discussion of healthcare rationing. As Professor Stirling Bryan
told us:
I also believe there is a need for a more open and
frank public conversation about rationing in healthcare. If one
is to get the public engaged and supportive of NICE one needs
to be much more open and frank with them about resource limits,
how decisions are made and the fact that there are very difficult
judgments to be made in terms of healthcare priority-setting and
rationing and that NICE is part of that.[227]
Dr Keith Syrett, from the University of Bristol,
also stated:
There remains a need to engage in a comprehensive
debate about rationing in the NHS in order to secure public acceptance
of the authority of limit-setting bodies such as NICE. [228]
He stressed that, "it is the function of government,
not of NICE, to initiate such a public debate".[229]
235. To date, however, politicians have shied away
from such a discussion, perhaps because it is uncomfortable to
talk about the 'cost' of a life (ie. the threshold that should
be used), or the maximum that should be paid to improve a patient's
quality of life. The subject of cost does not sit easily with
the concept of a NHS that is "free at the point of need".
Professor Nancy Devlin stated:
It is a very difficult debate to get going in the
current climate. A big policy issue within the NHS has been improving
patient choice. Patients should be able to choose what treatments
they get, where and when. That sort of theme around responsiveness
and individualisation of treatment alongside a debate on rationing
in the health service is somewhat uncomfortable, is it not?[230]
236. The problem is exacerbated by the threat of
legal action, which has been used to override PCT rationing decisions,
resulting in patients receiving the treatment they desire. On
rare occasions, as we have seen, Ministers have intervened to
achieve the same aim. Such actions may fuel public perception
that rationing is wrong and that denial of treatment is in a sense
cheating the patient. Dr Daphne Austin, a public health consultant,
claimed:
The perception that it is wrong to deny treatment
is fuelled by the fact that PCTs frequently step down when there
is a real threat of legal action. This is interpreted as an acknowledgement
of the PCT being 'in the wrong'.[231]
237. Mr Dillon agreed that NICE should play a role
in discussions about rationing, and that "the realities of
decision making" should be communicated:
I would quite like NICE to contribute to a broader
debate about why it is necessary sometimes for those controversial
decisions to be taken, and I think that has to be a debate that
involves government with its stewardship responsibilities for
the health service.[232]
Dr Austin concluded that without such a discussion,
achieving affordabilityand therefore determining the right
thresholdwas unlikely:
Until we can accept that not all needs can be met
we will continue to have a distortion in health service priorities
and, ironically, fail to get value for money overall.[233]
238. The Minister agreed that rationing was necessary,
and that NICE should play a part in public discussion of the subject:
in a cash limited system we clearly cannot pay for
absolutely everything so there needs to be an approach which attempts
to prioritise on evidence what is available. NICE has a role to
play in that in starting to shift the debate on to a more robust
footing that is about what the evidence tells us.[234]
She added that "transparency and engaging"
were needed to communicate to the public that not every medical
treatment or procedure is available for them through the NHS.
She also told us that "managing expectations", through
communication and better understanding of local needs, was necessary.[235]
Recommendations
239. The
threshold or ceiling NICE employs (measured in pounds sterling
per QALY) to decide whether a treatment is cost-effective, and
so should be available in the NHS, is not based on empirical research.
Nor is the threshold directly related to the NHS budget, since
the threshold has remained constant while the budget has increased
hugely since 1999.
240. The threshold
used by NICE does not take into account the funding decisions
made by PCTs generally. For interventions not assessed by NICE,
PCTs appear to use thresholds which vary from treatment to treatment
but for the most part seem to be lower than the NICE threshold.
241. Many PCTs
struggle to afford to implement NICE technology appraisals, as
well as clinical guidelines. As more interventions are evaluated
it is feared that the position will become unsustainable. Funding
is essentially ring-fenced for technology appraisals, leaving
PCTs little room for manoeuvre in their budgets to reflect local
needs and priorities.
242. A number
of steps were proposed by witnesses to alleviate the situation.
To improve coordination between NICE and PCTs, we support the
wider use of implementation consultants, who would provide information
both from NICE to the PCTs and from the PCTs to NICE.
243. There must
be incentives for clinicians to be very careful about the use
of expensive drugs. We recommend that current exclusion of high-cost
drugs from the payment by results tariff be reviewed.
244. It is difficult
for individual PCTs to decide which areas to prioritise and in
which to reduce spending when their expenditure rises as a result
of new NICE guidance. In the absence of NICE guidance on disinvestment,
we recommend that groups of PCTs should work together to determine
appropriate areas of spending in consultation with the public.
Such groups should also examine existing treatments to determine
which are not cost-effective.
245. While the
measures listed above would mitigate the problems PCTs face, the
fundamental problem which has to be addressed, according to several
witnesses, is NICE's cost-effectiveness threshold. Given the
uncertainties, for example about the thresholds used by PCTs,
we are not in a position to decide authoritatively whether the
current threshold, or threshold range, is appropriate. We recommend
that more work similar to that undertaken by Professor Smith and
colleagues at York University takes place on the thresholds used
by NICE. We are encouraged that NICE has commissioned its own
research in this area.
246. During
the inquiry, doubt was cast on whether NICE alone should continue
to determine the level of the threshold. We consider the present
situation is unsatisfactory. We recommend that a separate body,
with representation from NICE, the Department, PCTs and others
should set the level, or range, to be used. NICE's threshold should
be closely linked to that used by PCTs. The threshold should also
relate to the size of the NHS budget. The new body should decide
whether orphan drugs continue to be treated differently from other
treatments.
247. Demand
for NHS services will always exceed the ability to meet it. Not
every treatment can be provided to every person. NICE has a vital
role to play in the rationing arrangements and, working with Government,
should make clear to the public how and why such decisions are
made.
179 Q 540 Back
180
Q 531 Back
181
Q 531 Back
182
Ev 102, 152 Back
183
NICE 104 Back
184
Q 644 Back
185
Ev 32 Back
186
Ev 67 Back
187
Ev 62, NICE 103 Back
188
NICE 103 Back
189
NICE 103 Back
190
Q 182 Back
191
Ev 154 Back
192
Ev 62 Back
193
Ev 85, 110 Back
194
Q 645 Back
195
NICE 103, Appleby et al, BMJ 2007; 335:358-359 Back
196
Q 176 Back
197
Q 551. Professor Appleby suggested that NICE did not considering
individual PCT variation in delivery costs. Back
198
This work was undertaken by Professor Smith and colleagues as
part of the Quest for Quality and Improved Performance, a five-year
initiative of The Health Foundation Back
199
Q 184 Back
200
Q 643 Back
201
Martin S, Rice N, Smith PC: Further evidence on the link between
health care spending and health outcomes in England: http://ideas.repec.org/p/chy/respap/rp32.html
Back
202
Q 545 Back
203
Q 275, Ev 115 Back
204
NICE 103 Back
205
Q 302 Back
206
NICE 111 Back
207
Q 183 Back
208
Ev 180 Back
209
NICE 123 Back
210
Q 20 Back
211
Q 21 Back
212
Q 47. There may be problems with some cost templates though. We
were told of concerns with data contained in the costing template
for PCT commissioners that accompanied the clot-busting drug Alteplase
appraisal published in June 2007. NICE 123 Back
213
Ev 24 Back
214
Q 762 Back
215
Q 548 Back
216
Q 550 Back
217
Q 299 Back
218
Ev 243 Back
219
Q 271 Back
220
NICE 103. Initial research has revealed that a larger scale study
is possible, but that determining the basis of marginal decisions
(ie. cases where it is less obvious, or the data are less clear,
regarding investment or disinvestment in technologies) will be
difficult to unravel. Back
221
See Annex 1 for NICE's terms of reference Back
222
Culyer A et al. Journal of Health Services Research & Policy
2007;12;56. Cited Ev 77; Ev 118 Back
223
Q 533 Back
224
Q 645 Back
225
Q 648 Back
226
Maynard et al, BMJ 2004; 327: 227-229 Back
227
Q 222 Back
228
Ev 271 Back
229
Ev 271 Back
230
Q 556 Back
231
Ev 241 Back
232
Q 654 Back
233
Ev 244 Back
234
Q 716 Back
235
Q 717 Back