Examination of Witnesses(Questions 240-259)
PROFESSOR MIKE
RICHARDS CBE, DR
FELICITY HARVEY,
MS UNA
O'BRIEN AND
PROFESSOR SIR
MICHAEL RAWLINS
12 FEBRUARY 2009
Q240 Dr Naysmith: Are you confident
that your solution will end the top-ups debate? I do not just
mean by banning the use of the term in official documents.
Professor Richards: I do not have
a crystal ball but I think what I can say is that there has been
a huge amount of public concern about this, parliamentary concern,
media concern and very rapidly after 4 November when the report
was published that concern seems to be resolved. Many of my colleagues,
including the Royal College of Physicians, have broadly welcomed
the findings and most people are saying that it can be done; where
there is a will there is a way and this is a good way of going
forward.
Q241 Charlotte Atkins: We are now
going to move over to talk about the NICE thresholds for end of
life treatments. Professor Rawlins, how do you react to criticisms
that the reported decision to raise the cost per QALY threshold
to £70,000 for end of life treatments demonstrates that NICE
decision making favours inefficient and inequitable treatments?
Professor Sir Michael Rawlins:
There is a bit of a misconception here. We have not raised the
threshold to £70,000; that is the first point to make. We
have always stated that we have a threshold range of somewhere
between £20,000 and £30,000 per QALY but we have always
given our advisory committees latitude to go above and below it.
For example, when the effect of a treatment on the quality of
life has been inadequately captured by the conventional techniques,
as is the case in mesothelioma, the appraisal committee took account
of that and said yes at £37,000. When a new innovative treatment
comes along with very real and unique benefits like glycemic for
chronic myeloid leukemia the appraisal committee accepted that
at £34,000 this was a significant benefit. Sometimes there
are equities like the blast cell phase of chronic myeloid leukemia
where the appraisal committee said yes at £48,000. There
has been an incident going up as far as £60,000, a particular
treatment for children undergoing renal transplantation. The idea
that we have a fixed threshold is wrong. We try to balance equity
and efficiency. This is very difficult and in fact there have
been discussions amongst political philosophers since the time
of Plato and I am afraid I have not resolved this difficulty.
You do it all the time in Parliament; that is your job as politicians.
It is a balance. David Hunter said I was muddling through elegantly
and that is as a kind a description as I will probably ever have.
The one bit we do not do in our healthcare system is go to the
libertarian approach where it is your responsibility to look after
your own healthcare and your family's healthcare. That is the
American approach and having seen quite a bit of it over the last
few years I hope we never even begin to get near that.
Q242 Charlotte Atkins: Where does
this £70,000 come from?
Professor Sir Michael Rawlins:
I think a journalist attributed it to me but I do not know where
it came from.
Q243 Charlotte Atkins: There seems
to be quite a lot of leeway from £30,000 up to £70,000.
Professor Sir Michael Rawlins:
We have not got to £70,000.
Q244 Charlotte Atkins: I am interested
to hear that. Then we have the issue around so-called rarer cancers
and how you define that. We have already heard this morning that
the population of 7000 people has now been redefined to mean smaller
populations which seems to me even more woolly and more difficult
for organisations within the NHS to define it or to make a decision.
What are you saying around that?
Professor Sir Michael Rawlins:
We did originally say 7000 and the reason why we did it was because
there is a very clear distinction between the incidents of the
four big common cancers—colon, breast, prostate, lung—and
the rest. It is a big jump and it is quite clear it is around
7000. That is why we did it in the first version. However, although
that is very clear for cancer, many commentators felt that we
should be less restricted than this. Although it is very clear
for cancer it is less clear for other conditions and our guidance
is not cancer specific, it is all lethal conditions which have
the properties and the characteristics that we have specified.
People said, "We get what you're getting at but don't box
people in with 7000 otherwise you will find 7100 and then what
do you do?" So we have given some latitude to our appraisal
committees on that. All this recognises that the development costs
for treatments for less common conditions are going to be pretty
well the same as development costs for common conditions but the
market will be smaller and therefore the unit cost is likely to
be higher. We recognise that manufacturers may well have to charge
more for treatments for less common conditions. I want to be very
clear that we are limiting it to small populations; we cannot
do this for common lethal conditions. It would cost the health
service hundreds of millions of pounds a year.
Q245 Charlotte Atkins: Where would
you draw the line? Take oral cancer, for instance, which is about
the sixth most common cancer I believe.
Professor Richards: If you put
all head and neck cancers together that would probably be about
right. If you take oral cancer per se it would be considerably
lower down the list.
Q246 Charlotte Atkins: So it is going
to be very difficult for people to be able to define what a rarer
cancer is.
Professor Richards: I think in
cancer terms, as Sir Michael has said, we have four very common
cancers and all the rest we can call less common or rare. Equally
in the number of deaths that there are from these cancers there
is a distinction as well. Oral cancer will undoubtedly be a less
common cancer and would undoubtedly come within the small or 7000;
I am sure it would be covered by that, as would conditions like
myeloma or kidney cancer. All of those would be captured by the
small population or 7000.
Q247 Charlotte Atkins: Professor
Rawlins, you said that you have not raised the threshold but it
does appear that the threshold is rising over time and of course
the implications are that this then has a direct effect on PCT
budgets. If they are supposed to suddenly fund something which
has a higher threshold and that becomes more common, if they still
have the same budget—given the present economic situation
they are not likely to have big increases in their budgets—what
impact does that have in terms of NICE guidance to PCTs?
Professor Sir Michael Rawlins:
We have maintained the threshold range for a number of years now.
I have always said that this is not an empirically devised number
and you have heard from the previous health economists that it
is very difficult to know what that should be. People have been
asking us whether it should be raised in line with inflation.
Health economists are completely divided over this. James Raftery
has been published saying that the threshold is too high and should
be lowered. In the same edition of the British Medical Journal
there was another health economist saying that it was too low
and should be increased and Professor Karl Claxton from York thinks
it is about right. It is a great uncertainty and 10 days ago we
were planning to have a meeting which many members of this Committee
were going to come to at NICE to talk about this and hear some
of the experts but unfortunately the weather was so awful that
only Dr Naysmith managed to make it.
Chairman: It is back in the diary I understand,
Professor Rawlins.
Q248 Charlotte Atkins: When we look
at that clearly any increase in the threshold will have an impact
on the normal procedures which PCTs fund.
Professor Sir Michael Rawlins:
I think we have to be very careful there because although the
previous speakers spoke about the opportunity costs and that the
expense here would deprive other patients of care I think it is
important to ask Professor Richards about this because in his
previous cancer report he pointed out areas where there were very
considerable savings to be made in cancer care.
Professor Richards: If you look
at the total cancer spend in this country. £4.5 billion out
of the roughly £100 billion that we spend on the NHS goes
on cancer. The first thing to say is that less than 20% of that
is on drugs, less than a billion. That is an important element
of cancer spend but a minority. The large element of cancer spend
is on in-patient care; that is probably about 50% of the total
spend. What we pointed out in the Cancer Reform Strategy is that
there are huge opportunities for rationalising that in-patient
care which would benefit both patients and the NHS. That is where
I would really like commissioners really to target their efforts
ensuring that their local provider hospitals are using in-patient
beds as effectively as possible. We did some studies looking at
individual hospitals around the country, getting experts from
overseas to come and work with clinicians and managers in this
country and in every one that we went to by the end of the session
the people from this country recognised that there was a lot they
could do to reduce their in-patient care. We have set up a programme
through NHS Improvement which is piloting this across the country;
I would just encourage commissioners to get involved with this
because we estimate that there is £350 million worth of in-patient
care that could be released for other purposes. That is where
there is headroom to do a lot of the things that we need to do.
Q249 Chairman: Presumably that would
be balanced by primary care.
Professor Richards: That is net
saving. Yes, there are things you would have to invest in in order
to make that saving, but that is the net saving we believe would
be possible.
Dr Harvey: At the moment the NHS
spends about 12% of its budget on drugs and, as Professor Richards
has said, a lot of the rest of the care is the non-drug care.
Through the work that Lord Darzi did in his next stage review
one of the recommendations that we have that is currently being
implemented is the development of NHS Evidence. One of the issues
that came up from a huge amount of evidence both in this country
and abroad about barriers to innovation was the fact that there
is a lot of information for the NHS, but it was all in different
places and was quite difficult to access. NICE provide a lot of
it but there is a huge amount of evidence elsewhere. What we will
have through NHS Evidence—which will be hosted by NICE and
is being developed by NICE—is a single portal for the NHS
for patients, commissioners and for clinicians et cetera, one
place where all of that evidence can be established. NICE guidelines
in terms of its drugs will be on there but also clinical guidelines
from NICE and many other places, as well as allowing a place for
clinicians that are, for example, looking at new pathways of care
to actually have that in one place as well. I do think we need
to remember that the drugs are important but it is actually 12%
of total spend. That may vary over time but there is actually
an awful lot we need to do about care in its totality as Professor
Richards has said within the Cancer Reform Strategy.
Q250 Dr Taylor: The previous witnesses
rather cast doubt on willingness to pay as a valid role in shaping
NICE policy. I was going to ask exactly how you asked that question
and whether it took into account opportunity costs although you
have rather pooh-poohed the idea that opportunity costs are much
of a problem. When you put this to the public survey did you make
the point that if you get more of X you have probably got to get
less of Y?
Professor Richards: The first
point to say is that opportunity costs obviously do matter. What
I was trying to do was point out that there are areas where there
is very little health gain in patients spending unnecessary time
in hospital; it may be the opposite of health gain. Those are
the areas that we ought to be looking to decrease our expenditure.
That is where I would see that there is the headroom to move forward.
We approached the issue of willingness to pay in a number of different
ways. First of all, would people want to be allowed to pay and
all the evidence there is that four-fifths of the population are
saying they would want to be allowed to pay on top of NHS care.
Cambridge University Hospital did some work where they asked people
how much they would be prepared to pay. Only 120 people responded
to this but over 50% of them said they would pay up to £10,000
and 30% of them said they would pay £30,000.
Q251 Dr Taylor: That is Cambridge,
mind you.
Professor Richards: I accept that
but interestingly my clinical colleagues, the oncologists, did
a survey of their own members and asked what happened to people
when the PCTs had said no. This is only one survey but around
half of those patients were ending up paying themselves. That
came as a shock to me that it was at that level. I think we would
need to try to replicate that data and see if that is happening
and we plan to do that through auditing unfunded drugs in the
future. If that is the case it does show that the people who are
in this situation themselves are willing to pay. Indeed, that
builds on research that was done almost 20 years ago that I was
involved in where you ask cancer patients who are in the situation
that these patients are, where they are facing life and death,
about their willingness to go through intensive treatment—we
were not asking them to pay for it at that stage—and is
very much higher than if you ask the same question to age match
controls in the population. So I think we do know some things
about this. Equally, during the course of the review, the message
that came through in a number of different ways from a lot of
different people was that we do expect the NHS to look after people
who are in extreme situations. Whether that is very disabled children,
we would not want to put a limit of £30,000 on their care
each year; we would spend a lot more than that. If it is premature
children we may spend more on that. If it is people who come in
following a road traffic collision we would spend more on that.
We do believe that there is some particular value for people approaching
the end of life. I do not have numbers for that but that was the
message that was coming through from the engagement exercise we
were involved in.
Q252 Dr Taylor: The end of life drugs,
these are technology appraisals so they will be mandatory.
Professor Richards: Yes.
Q253 Dr Taylor: Professor Rawlins
probably remembers the very first inquiry we did into NICE which
is going back some years, but I shall never forget the people
from across the River at St Thomas's when you were talking about
implantable defibrillators they said quite clearly they would
far rather have more nurses in the A&E Department than the
implantable defibrillators. Even though these are mandatory, if
a given PCT feels very strongly that it has a much more important
priority, what will be the position for that PCT?
Professor Sir Michael Rawlins:
They will be in breach of the law. There is a direction from the
secretary of state that they should provide them; it is enshrined
in the Constitution.
Q254 Dr Naysmith: Following up on
that exchange Professor Richards, some people have suggested that
instead of increasing expenditure on cancer drugs that only prolong
life for a few weeks or a few months, PCTs would be better to
spend their money on more cost effective areas such as prevention
or services such as palliative care. From what you have said I
think you probably do not agree with that.
Professor Richards: Far from it.
Q255 Dr Naysmith: Taken together
the money would be better spent on these things.
Professor Richards: My job as
National Cancer Director is to maximise the benefit for all people
who may now or in the future develop cancer. I certainly want
to see investment wherever we have evidence that it is going to
be of benefit. We have evidence of cost effectiveness on things
like screening programmes. We know those are highly cost effective;
we are extending the breast screening programme and the bowel
screening programme so we are doing a lot in those areas. I would
be very worried if we were not able to do that because those do
undoubtedly save lives in the long term. Equally we need to put
more investment into encouraging patients to come forward earlier
for diagnosis when they do get symptoms because we have heard
a lot over the years about the differences between our survival
rate and those in Europe. What we know is that it tends to be
because of later diagnosis that we have a poor survival rate.
I am extremely to make sure there is investment in those areas
which tend to be highly cost effective.
Q256 Dr Naysmith: If that is the
case and the evidence suggests that, would it not be better to
spend this extra money that we are spending on this on earlier
diagnosis in this country?
Professor Richards: I think there
is always a balance and what I am also saying is that we believe
there is an even larger chunk of resource that can be released
to do both of these and that is the resource that is currently
tied up on in-patient care for cancer patients. That is why we
set that out very carefully. The whole of chapter seven of the
Cancer Reform Strategy tells people that that is what they can
do.
Q257 Dr Naysmith: Yes, but what you
are doing is telling somebody else to save the money.
Professor Richards: I am telling
the health service and telling local health economists that these
are areas where they can relatively simply save a great deal of
money for the benefit of patients and, at the same time, that
will then release the resource to save lives through earlier diagnosis
and to improve the lot of people who are coming towards the end
of their lives.
Q258 Dr Naysmith: Given the recession
and reduced future funding of the NHS, which is almost inevitable,
is it time to alter the NICE legislation to make it responsible
for its own budget and for the budgetary consequences of its guidance?
Professor Richards: I have to
say from my point of view, particularly with this new scheme that
has come in, I believe that working with NICE is working very
well. I have had a very fruitful relationship working with NICE
over the last nine years since I have been in my post. There are
things we have had to improve—the timeliness of NICE we
have already talked about—but I believe we have it just
about right at the moment.
Professor Sir Michael Rawlins:
I think what you are suggesting is that there should be a pot
of money.
Q259 Dr Naysmith: There is one country
that does it.
Professor Sir Michael Rawlins:
I do not know, but it has been suggested before. There are several
problems with it actually, one is, how big is the pot? One year
you might want a slightly bigger pot than another year. That is
one problem; nobody knows how big the pot ought to be. Should
it be £100 million or £150 million? We do know that
if NICE's advice is taken up completely the consequence in budgetary
terms is about £1.5 billion. We are talking, on average over
10 years, £150 million. I am not ashamed of that; it is money,
in my view, well spent; it is demonstratively clinically cost
effective. The other problem with having a pot is that the appraisal
committees would be more tuned into the budgetary impact of their
decision rather than cost effectiveness.
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