Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 28 - 39)




  28. Can I welcome our second group of witnesses and express my appreciation to you for your cooperation with the Committee in this inquiry and for your written evidence. Could you each initially introduce yourselves to the Committee? Could you, in doing so, indicate any involvement you have had to date with any funding that your organisation or you have received from drug companies? Obviously it is of some relevance to our inquiry.
  (Mr Moore) My name is Andrew Moore. I am a biochemist and the executive editor of Bandolier, which is an evidence based news letter in the NHS that has a very large website which has the best part of 200,000 visitors per week. I am also a researcher in pain research, particularly in areas around evidence based medicine. I have had very little contact with NICE apart from on the basis of an expert witness, looking at the evidence on one product base, the coccyx, for a pharmaceutical company. For 25 years, I have worked in various aspects of research, much of which has been funded by government, some of which has been funded by pharmaceutical companies and some of which has been funded by charities. We work to one rule only and that is that any work we do should be published and we have the absolute right to publish which I believe gives us a degree of independence which is quite important in this area.

  (Professor Walley) I am Professor Walley. I am Professor of Clinical Pharmacology at the University of Liverpool. I am also a consultant physician in the NHS and chairman of the Drugs and Therapeutics Committee at the Royal University Hospital. I have been involved in studying prescribing as research for the past ten years. Currently, I have had no funding from the pharmaceutical industry but I do hold funding as one of the units responsible for producing technology assessment reviews on which NICE would base its appraisals.
  (Mr Newdick) I am Chris Newdick. I am the reader in health law at the University of Reading. I am also a member of the Priorities Committee on Berkshire Health Authority. I have no other connection with NICE.
  (Dr Duerden) I am Martin Duerden. I am a part time GP. I have had a long interest in matters relating to medicines policy, evidence based medicine and prescribing advice. I have worked for the National Prescribing Centre which receives funding from NICE and I am currently working for Prodigy, which also receives funding from NICE. I have been involved with a pharmaceutical company in terms of helping to prepare a submission to NICE.
  (Professor Kendall) I am Martin Kendall and I am the chairman of the Joint Formulary Committee which produces the BNF, which I think is why I am here today. I am also a member of the Committee on the Safety of Medicine. I am a Professor of Clinical Pharmacology in Birmingham and my day job is as a consultant physician in Birmingham. I have no links with NICE at all and I have no direct financial links with any member of the pharmaceutical industry.
  (Mr Mehta) My name is Dinesh Mehta. I am the executive editor of The British National Formulary. We have no direct links with NICE; nor do we have any links at all with the pharmaceutical industry or any direct links with the Department of Health.

Siobhan McDonagh

  29. Dr Duerden, you argue in your evidence for separating decisions about clinical effectiveness from affordability. What should NICE do?
  (Dr Duerden) That is a very tricky question and I wish I had a very clear answer to it. It is something that needs to be thought through very carefully because at the moment it is in a very difficult position in terms of giving a view on cost effectiveness and expecting people to be able to afford to provide that alongside a lot of conflicting other priorities. One way round that is to maybe suggest that some of the work of NICE could be a National Institute of Clinical Evidence. It could do a pure, evidence based medicine report that would take into account all the advice and information that it provided for and, at that point, also look at the potential impact of using the therapies within clinical practice, what the particular costs may be, what the resource implications may be and maybe at that stage hand that package across to another body that decides on how affordable that is, whether it fits within the NHS priorities or alongside things like national service frameworks.

  30. Last week I went to see the chief executive of a hospital trust close to my constituency who expressed concern about the timing of NICE guidance and you make reference to that in your evidence. Could you explain what you mean when you refer to NICE flight?
  (Dr Duerden) It is a slightly pejorative term. Maybe I should not have used it but it has been used by quite a lot of other commentators on this subject. It is a situation that has arisen and I do not put the blame on NICE. It is just the situation where it has been expected to prepare a lot of guidance almost immediately, as soon as it comes into being, and there is a backlog of things that need handling. There are many issues within clinical practice where you really want decisions made very clearly. Unfortunately what has happened is that the providers, the people responsible for making decisions about whether a therapy will be provided, have been placed in an invidious position. They cannot give a positive proposal in case NICE comes along and contradicts that. They cannot give a negative proposal because the Department of Health says that it is not appropriate not to make a decision on this matter. At the moment, that has created major problems for many health care organisations. They really are trying to just hold back until they get their various determinations through so that they can make proper planning and strategic decisions. It has made a considerable difficulty, in many respects, worse than it was before. Hopefully, that will get resolved as time goes on.

Sandra Gidley

  31. I wondered if it went a stage further than that. You do not know what NICE is going to appraise. It is a fairly obscure process and I cannot quite see the logic or the continuation of thought behind it, but is there sometimes the thought that this is a new drug? It is likely that NICE might look at it and people are waiting on that decision before they make their own and it goes back a stage beyond that which you have just identified.
  (Dr Duerden) It would be difficult to cite evidence, particularly around things like cancer therapies. You can see new therapies coming along there beginning to emerge as possible useful interventions, but at the same time you are aware that there is a prioritisation list for NICE and you are not quite clear whether that particular procedure would be on the NICE list and therefore you hang fire. It is a lot of resource to do this type of evaluation. It needs a lot of expertise. You might not want to use that expertise locally when you have other things to get on with and therefore you hang back and you wait.

  32. The whole thing is a delay to the patient?
  (Dr Duerden) Yes.

Siobhan McDonagh

  33. You also suggest that NICE should have greater independence from the political processes. What evidence do you have that it is not independent?
  (Dr Duerden) I do not. It is a perception and that perception needs to be dispelled.

  34. How do you dispel perceptions?
  (Dr Duerden) We talked earlier on about the issues in relation to Relenza and the reversal of the decision. That created a perception that maybe NICE had been got at, that it had made a change in response to major political pressure, pressure from the media and the drug industry.

Dr Naysmith

  35. Do you think it was got at?
  (Dr Duerden) I do not know but it gave that impression. I think we need to try to dispel that impression.

Siobhan McDonagh

  36. Could you also argue that it was being receptive to all sorts of people's views and in another world, if we want patients' groups and everything else to have influence, perhaps decisions or ideas do get changed because—
  (Dr Duerden) I can see that. That is the problem. That is a real dilemma in terms of getting that balance right. We want a body that will take account of many different issues such as evidence based medicine, which I personally think should be the driving force, but also things like patient requirements, patient needs, the things that they think are most important and that can meet political expediency as well. Therefore, getting that balance can be very difficult.

  37. How do you stay independent?
  (Dr Duerden) One of the ways would be what I have suggested which is that you have an evidence based body which makes very specific appraisals of the evidence and the implications of using those therapies and maybe leave another body to respond to all those political and other pressures to make a decision. We have a problem at the moment in that we are expecting a single body to deal with everything. I am not sure how practical that is.

Jim Dowd

  38. On affordability, given that there will always be a finite limit on the funds available for the health service generally, let alone the pharmaceutical budget, and given the advances in pharmacological technology in recent years, surely any assessment that is just purely technical and is not informed by affordability is going to be of diminishing value because money spent on one thing is clearly money not spent on the other.
  (Dr Duerden) There are quite a few different components to that argument. You end up having a philosophical discussion. I think that needs to be sorted out, but you could spend a long time discussing that. One element is removing interventions which are ineffective, where there is clear evidence they are ineffective. I do not think we have been very good at doing that. That is one element to make sure you use resources wisely. There are other elements in terms of affordability, in terms of making sure that when you look at a particular treatment you look at it in the total management package that is involved in that treatment. One of the concerns I would have about the NICE appraisal system is it is looking at very specifically focusing on an individual drug rather than looking at the overall care of a patient. If you are going to deal with affordability, you really do need to get into that area. NICE does have a remit to get into guidelines and that is beginning to develop. I see the real future in the strength of NICE as being around having good clinical guidelines to make sure that we maximise intervention appropriately.

  39. That implies a broader, more comprehensive approach to affordability rather than ignoring it altogether.
  (Dr Duerden) Yes, I agree. There is a dilemma there again because I am saying let us step back and take a very narrow focus in terms of evidence based medicine but then you need to put that in the context of the overall care of the patient. That can be done but I am not sure that the process is correct at this point in time.

previous page contents next page

House of Commons home page Parliament home page House of Lords home page search page enquiries index

© Parliamentary copyright 2002
Prepared 8 July 2002