Top-up fees - Health Committee Contents

Examination of Witnesses(Questions 240-259)


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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