Examination of Witnesses(Questions 280-291)
PROFESSOR MIKE
RICHARDS CBE, DR
FELICITY HARVEY,
MS UNA
O'BRIEN AND
PROFESSOR SIR
MICHAEL RAWLINS
12 FEBRUARY 2009
Q280 Dr Naysmith: Professor Richards,
does it matter that some European countries spend proportionately
more on cancer drugs than the NHS does? We heard in the previous
session that there is some doubt about the figures but there seems
to be some feeling that it is true that they spend more than we
do on some cancer drugs.
Professor Richards: The first
point to make is that I think there is clear evidence that overall
we spend less on cancer drugs than some European countries. We
published that figure—about 60% of the EU average—in
the Cancer Reform Strategy. I think the issue we need to get behind
is why and does this relate to some drugs and not other drugs
and what factors may be behind it? That is the work we want to
do this year because I do not think it is as simple as having
a yes or a no from NICE. Also, what are the views of clinicians
of the relative benefits and the relative harms? Most of these
drugs have quite considerable side effects as well as benefits
and in general I would say that clinicians in this country are
more cautious in their use of the drugs than clinicians elsewhere.
I am sure it does not necessarily feel like that to PCTs who are
getting all the requests for these drugs, but I can assure you
that that is my assessment of it. As you probably know we have
done extensive look-backs in this country to see what variation
there is within this country. I think we want to build on that
and we want to look at a range of products within cancer—although
this can go beyond cancer—and those products that were licensed
within the last five years, those that are six to nine years old
and what about the drugs that have been around for ages where
cost is not usually the main limitation. I think we need to look
in detail at that to get a clear idea. I think we need to work
with clinicians from other countries to find out whether the comparisons
are valid because there is always that question of whether we
think the comparisons are valid.
Q281 Dr Naysmith: I think you said
earlier that there was some element of earlier diagnosis giving
better results in some countries.
Professor Richards: We are doing
two different international bits of work, one is on the early
diagnosis side which we are doing in collaboration with Cancer
Research UK and a completely separate one which flows on from
my review which is looking at usage of drugs and trying to find
out what is, as near as one can get, optimal usage of those drugs.
Ms O'Brien: Perhaps I could add
to that on a more general level that this is precisely the question
that we need to ask ourselves across all the different dimensions
of care in relation to achieving better outcomes for our population.
I think it is one of the reasons why Lord Darzi places it so central
in his review. As we look forward into 2009 we will be establishing
the National Quality Board chaired by the NHS chief executive
which really, for the first time, is going to bring together—looking
at the comparison and performance of the English NHS with the
health systems of other western developed countries—all
the differences that there are between them, trying to get behind
in more depth and to share systematically the evidence about the
bad outcomes and to see what we can do to up our game here. I
think that is a really significant development in being honest
that we have some really important things to learn and we need
to get smarter international comparisons. They are fraught with
difficulty which I think the evidence in the session before indicated.
We are not necessarily comparing like with like. The point really
to make is that we know that this is the next place we have to
go.
Q282 Dr Naysmith: Professor Richards,
the October 2008 report by the London School of Hygiene and Tropical
Medicine which looked at how other countries fund expensive drugs,
did that influence your recommendations at all?
Professor Richards: Up to a point.
What it did show was that there are different approaches both
for the assessment of these drugs and there are differences in
which drugs are available. What it showed was that we needed to
go even further beneath that to understand these variations and
that we also needed to look quite separately at the data on drug
utilisation per thousand population in these countries and that
is what we will be doing. I think it is a useful foundation for
the work that we are going to be doing this year looking at variations
in drugs.
Q283 Dr Naysmith: I think that report
showed that some countries have found it difficult to separate
public and private healthcare. What makes you think that the NHS
will be able to succeed where other countries have failed?
Professor Richards: They are completely
different systems of healthcare; they are radically different.
However, we will look at all of those things in terms of whether
we are really counting like for like. That is the important point.
If we are going to come out with any statements about where we
are on an international league table we do need to know whether
that is a fair comparison or not.
Q284 Dr Taylor: Right at the end
we are coming to the dreaded word, the "R" word—rationing.
I think everybody agrees with the increasing longevity and increasing
possibilities for treatment there is no way the NHS is going to
be able to go on affording absolutely everything. NICE is the
first excellent beginning of healthcare rationing in a particularly
limited field really. I am delighted to have two top officials
from the department here because they can tell me why an adjournment
debate I tried to have some months ago entitled "NHS Rationing"
was changed to "NHS Prioritisation". Why will the Government
not face up to the fact that we have to start having an open discussion
across the whole country about what the NHS must afford and what
is possibly going to fall off the bottom? One of our first witnesses
said that there are 25,000 interventions in the NHS and obviously
some of those are of enormous value, cost effective, very low
figures. Why can we not start an open debate on what perhaps we
should not be affording because we cannot afford everything? Can
we use the word "rationing"?
Dr Harvey: I cannot comment on
that because I do not know about the background. However, I would
say that having NICE as an organisation is extremely valuable
for the NHS because, as you know, their remit is much, much wider
than just the technology appraisals and I think, as I said earlier,
the fact that they now have NHS Evidence which they are developing
as well to look across the piece in terms of the best evidence
there is that clinicians, commissioners and indeed the patients
will be able to access I think is very important. As you know,
NICE does not just look at clinical care and technology appraisals,
it also looks at public health. What we need to be doing is looking
right the way across public health disease prevention as well
as the treatments for people who actually have active disease.
Looking at the clinical and cost effectiveness of those within
the NHS budget which is sizeable—it is about £96 billion
this year—is, we feel, the way we need to go. Also, as the
Chairman raised earlier, there is the issue of disinvestment.
Where we think there is care that is actually outmoded and there
are better ways that care can be provided, then that needs to
be taken forward. The other thing we do need to remember is that
there is a lot of emphasis on new drugs that come forward which
are an added cost to the NHS. I think we must remember that actually
a number of these innovations will actually change a pathway of
care and change a pathway of care quite dramatically which can
then use less bed days which can actually make a patient pathway
very different, we be able to move secondary or tertiary care
into the community. All of those things are things that we need
to be looking at together in terms of how care is provided.
Ms O'Brien: There is little that
I would add to what Felicity has said. I think these things come
back fundamentally to what is the Government's policy towards
the NHS as a whole and how do we best preserve the principles
and the universality of the NHS in the context of the fast moving
developments in technology. I would re-enforce what Felicity said
about NICE. This is not really so much about rationing as about
getting smarter and better at disinvesting and stopping doing
things that are ineffective and finding and harnessing those technologies
that will enable people to stay healthier for longer. Many things
that on the face of it appear expensive are in fact effective
in terms of maintaining people's health in the longer run. I think
it is about our purpose and our overall objectives. How do we
find a way through this? I was very struck by the comments that
Bill Gates made at Davos when he talked about the three drivers
for economic development over the next 10 to 15 years would be
medicine, technology and software and really they are three things
that come together very powerfully in relation to health systems.
It is not just we who are faced with this challenge, all health
systems are looking at ways in which they can harness technology
in order to use the resources most effectively. I do not see it
really as a situation where the resources are all allocated and
now we are going to have to rush them back in order for them to
be affordable, it is actually about how we can use innovation
in order to get more effective use of our resources and better
health at the same time.
Q285 Dr Taylor: Whatever you call
it, how should the public be involved in this? I know NICE has
their citizen's panel but that is relatively small in the amount
it can do. How should a widespread public debate be stimulated?
Or should it be?
Ms O'Brien: Obviously Professor
Rawlins can speak about the approach that has been developed by
NICE which, particularly in relation to patient and public involvement,
I think is absolutely showing the way not only for organisations
similar to NICE elsewhere in the world but actually showing to
the NHS just how you can really start to involve public and patients.
The key development in terms of public involvement now is very
much focussed on PCTs and the role of PCTs in facing out to their
local population. We have clearly set a course there with the
approach of world class commissioning and we have a long we to
go. However, I think the absolute importance of the PCT linked
with, for example, local authorities and other partners, is to
be much more engaged with and facing up to the needs of the local
population and really listening to what people want and need and
engaging them in that debate. It is the direction of policy even
though we have much to do in order to improve the practice. We
have some really great PCTs on that front and others who have
a way to go.
Professor Sir Michael Rawlins:
I have never liked the "rationing" word because I am
old enough to remember ration books and sweet rationing and things
like that, but if you want to use it let us call it rationing.
People generally do now understand that rationing in healthcare
is necessary, that there is not a bottomless pit of money. It
is not a matter of whether we do it but how we do it. How do we
do it fairly? I think we need to learn more how to do it. We have
our citizens' council and that is there to help us with the social
value judgments that you were talking about earlier. The great
fault with it is that it is only 30 people and they are drawn
roughly at random but do they really reflect everybody's views?
I am not a social scientist but we do need to develop better mechanisms
and methods. I feel that things placed on the internet might well
have great possibilities for the future. I am struggling to think
of a way and nobody has really come up with a sensible one. The
only thing I can say about the citizens' council is that we put
the reports out for consultation before they come to the board
and interestingly enough nobody has really criticised any of their
reports; there has been no major hoo-hah about what they have
said.
Q286 Dr Taylor: Surely it has to
be a national debate because if it is left to PCTs then we really
will be down to postcode differences.
Professor Sir Michael Rawlins:
How do we have a national debate? It is not easy. It is the Daily
Mail arguing with the Telegraph, with the Guardian,
the Times and the Financial Times. That is what
happens.
Q287 Dr Taylor: At the risk or raising
a complete red herring, it is patient and public involvement in
health which has been ruined?
Professor Richards: During the
course of the very large scale engagement exercise that I was
engaged with for my review we did hear a very large majority of
people say that they did accept there is a limit. That was the
way it was being phrased by the public. Not everybody; there were
some people who thought we should pay for everything. Wherever
we went there were one or two saying that, but by far the majority
said that they did accept there is a limit. I think also people
were saying that they do expect the NHS to get rid of any waste
as one of its first priorities. In its prioritisation I would
prioritise getting rid of the waste and driving that efficiency
and there is still a lot more we can and should do on that.
Q288 Jim Dowd: On the 3% figure for
the drugs use in the UK, is that by volume or by value?
Dr Harvey: I think so but we will
have to come back to you. We were 3.3% of the global market for
pharmaceuticals in 2007.
Q289 Jim Dowd: Also we are only less
than 0.1% of the world's population.
Dr Harvey: We do have 9% of global
R&D for pharmaceuticals in 2006. I have just been told it
is 3.3% by value.
Q290 Jim Dowd: How has that figure
changed over time?
Dr Harvey: It has stayed roughly
the same. Some people say 3%, some say it is 3.5%. It is in the
region of 3% to 3.5% and it has stayed, as far as we know, roughly
about the same. I think that is why we cannot be a price maker.
Q291 Chairman: Professor Richards,
is it true that we all accept there are limits in health service
expenditure until we are ill? The real issue is not about the
generality of the public because they are not the ones who are
batting around between the Daily Telegraph and other tabloid
newspapers and broadsheets. That is the hard reality of it. Looking
at it from the base of the community is not looking at it from
the base of the individual concerned. That is the problem you
have and we have in coming to decisions, is it not?
Professor Richards: You have to
remember the engagement exercise that we are going through, yes
we did engage with the public through focus groups but we also
engaged with a lot of patient groups and even within those patient
groups there was an acceptance by and large that there is a limit.
I am not saying that everybody accepted that but there was an
acceptance by and large. The difficulty in trying to find out
from large scale polls of the public is that it does depend how
you frame the question. Just before my review started there were
different papers that conducted different reviews and came to
diametrically different results, but that was dependent on how
the question was framed.
Professor Sir Michael Rawlins:
I think one can easily underestimate people's generosities. Years
ago when the beta interferon thing was happening I was asked to
go and speak to the Multiple Sclerosis Society in Newcastle. I
went in fear and trepidation and they were very kind. Afterwards
I found myself ringed by four or five men in wheelchairs who said,
"We want to talk to you". I thought, "Oh dear"
and then they said, "We realise there is a problem about
this drug. We want you to know that we all think that the kids
over there who are still walking should have priority, not us."
I thought that was an extraordinary statement.
Chairman: That is a nice statement to
finish on. Could I thank all four of you for coming along this
morning and helping us with this evidence session.
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