Select Committee on Health Minutes of Evidence

Memorandum by Lambeth, Southwark and Lewisham Health Authority (NC 47)


  1.1  In response to this request from the Select Committee we have undertaken a brief consultation exercise across the local health economy in order to provide a collective approach to some of the questions raised during this inquiry.

  1.2  One of the key outcomes of our consultation has been the need to recognise the existing tension that exists between national guidance and local need. On the one hand we recognise that post-code prescribing should be abolished. On the other hand we have local priorities which need to met. Local health economies need flexibility to allow an effective approach to this tension.

  1.3  For the purposes of this response we have concentrated on the following two points asked of us:

    —  Has NICE ended confusion by providing a single national focus?

    —  Is NICE providing guidance that is locally owned and acted on in the right way?

  1.4  Our two main recommendations are:

  If the government wants a single national focus and wishes guidance to be owned and implemented consistently, then NICE recommendations will:

    —  have to be priced appropriately;

    —  be included and transparent within the Comprehensive Spending Review discussions;

    —  come with full earmarked funding so that local commissioners can meet local needs without distorting existing priorities and allow for differential needs and priorities to be addressed.

  To increase local ownership and implementation of NICE guidance, what NICE considers is of crucial importance. A full consultation process with health care commissioners, providers and patients should be undertaken when deciding NICE's portfolio of interventions as this impacts greatly on what can be achieved locally.


  This evidence is being submitted by LSL Health Authority to represent the views of its constituent Trusts and NHS purchasers. The views have been prepared by its Prescribing Committee and Chief Executives and Finance representatives of Trusts and Primary Care Groups. Given the timing, however, there has been limited opportunity to fully consult colleagues.


  LSL is a health authority responsible for a population of approximately 730,000 in South London. It has huge health needs, and despite an annual healthcare budget of over £900 million finds difficulty in adequately meeting all the healthcare requirements of these needs. LSL has six Primary Care Groups, shortly to become three Primary Care Trusts. It also has three Acute Teaching Trusts (Guy's and St. Thomas', Kings', University Hospital Lewisham), one Community Trust (Community Health South London) and one mental health trust (South London and Maudsley)


  We welcome the setting up of NICE. The independent assessment of the evidence into the efficacy and appropriateness of new drugs and interventions has provided clarity and eliminated duplication of this work by health authorities. The centralised approach to these assessments that NICE now provides has also provided welcome standards in how these assessments are done, although we do not agree that Randomised Controlled Trials are always the only gold-standards.


  5.1  We have chosen to concentrate on this as this is the area in which we have collectively done the most work locally.

  5.2  Our main concerns relate to affordability and prioritisation of drugs for our local population in relation to need (table 1). The NICE portfolio of drugs does not reflect our local needs and priorities as shown in table 2.

Table 1


Areas for which the burden of disease is above the England average, which might need additional investment
Chronic liver disease and cirrhosis
Coronary heart disease and stroke
Infectious diseases
Mental health problems inc. suicide
Sexual health problems
Thalassaemia and sickle cell disease

Table 2


LambethSouthwark LewishamNICE*
Coronary Heart Disease and strokeCoronary heart disease and stroke Coronary heart diseaseCancer
Sexual healthSexual health Sexual HealthObesity (also prevents CHD)
Older peopleOlder people   Rheumatoid arthritis
Mental HealthMental health Mental HealthHepatitis C
ChildrenDiabetesDiabetes Acute CHD
  Disabilities   Alzheimers disease

  *Priorities derived from proportionate increased NHS spend implied by guidance from March 2000.


  6.1  Drugs are not necessarily the most important component of treatment and care from patients' perspective and should be considered as part of the overall care pathway for treatment. Local health services need to get the right balance of care and spend for the patients between acute and primary care and to ensure that patients receive the appropriate components of their treatment, which are not necessarily drug-based. For instance, mental health rehabilitation may be more important for some patients than drugs.

  6.2  We need to be able to deliver a pattern of care appropriate to locally assessed needs an example is given from a study to map services for people with Multiple Sclerosis and to identify priorities for further investment. It identified the views and needs of 40 patients with Multiple Sclerosis living in LSL in 1997/8. It was undertaken on behalf of the MS review group, composed of patients and professionals.

Table 3


MS Study - patients' determination of their needs: priorities for funding NICE guidance: priorities for funding
Counselling at the time of diagnosisBeta interferon
Information and education, possibly from an MS nurse   
Transport to and from outpatients and physiotherapy   
Benefits advice and aids  
MS Specialist nurses  

  6.3  When asked about whether they wanted beta interferon which had been licensed in 1996, most patients said that they wanted more information, but not necessarily the drug as the only top priority. Although the results of this study are now outdated, the process illustrated that whilst the media suggested that all MS patients wanted the drug, that was not the case locally.


  7.1  Last year we experienced extreme pressure on resources locally. Because we have a huge burden of need to meet locally we were only able to allocate £2 million above inflation to meet the additional cost of new drugs including those recommended by NICE (excluding cancer drugs for which we had a separate allocation). This meant a shortfall or of £2.6 million. This budget has been exceeded in primary and secondary care. Indeed, we used a rationing process to ensure distribution of our funds to those conditions of greatest need and to achieve financial balance in the local health economy. In secondary care we were only able to guarantee to meet the costs of two categories of new drugs: glycoprotein inhibitors and drugs for renal transplants; and partially guarantee atypical antipsychotics for severely ill psychiatric patients.

  7.2  This year NICE guidance must be fully implemented. Full implementation of NICE guidance would require rationalising or cutting-back on other services and developments including meeting all the key targets within the NHS Plan. We have calculated that NICE implementation all expected NICE guidance will place an additional cost on us of approximately £15 million in the financial year of 2002-03.

  7.3  The requirement to fully fund treatments recommended by NICE, will prevent us from funding other treatments needed by our local population but which are not yet subject to NICE guidance. An example is the new disease modifying anti-rheumatic drugs. NICE has approved the use of virtually all the drugs it has examined so far[2].


  8.1  We are currently preparing for next April's annual development plan (previously Service and Financial Framework) and have increased growth money for the NHS. However there is no earmarked funding for NICE guidance and this is not one of the priorities in the Priorities and Planning Guidance, except for cancer.

  8.2  In the absence of earmarked funding for NICE implementation local organisations face major problems and are likely to tackle them in different ways. Some Trusts feel that this is a commissioner problem. Others feel that in the absence of full funding they may be unable to sanction prescribing, because of their statutory requirement to achieve financial balance. Chief Executives of Trusts need to reserve the right not to fully implement the guidance.

  8.3  If the guidance is not fully implemented with earmarked funding there will be different decisions in different places. This will result in "post-code prescribing".


  9.1  Ethical dilemmas; This health authority held a conference to examine ethical and legal issues surrounding such decisions. The Chief Executive of NICE attended to make a presentation. The outcome of the conference suggested that NICE guidance alone could not end post-code prescribing, it was up to local determination as to how to prescribe or fund it. Legal opinion suggested that at that time NICE guidance was guidance and that health authorities and others were entitled to take the total resources available to them into consideration in deciding their priorities. As long as they had an explicit process for decision-making, which involved applying specific values and was transparent, that would be permissible even taking into consideration the requirements of the Human Rights Act.

  9.2  Timing of determinations: If a determination is expected it should be available before prescribing or the new technology has diffused into practice. Further delay can occur if the guidance is subject to appeal. An example in both instances is the prescribing of beta interferon.


  In summary this health economy:

    —  welcomes the robust appraisals of NICE;

    —  regrets that it cannot afford to fully implement prescribing of NICE recommendations without cutting back existing services and developments;

    —  considers that other services or interventions including drugs may have a higher priority locally for funding than NICE guidance and so there should be local determination of funding priorities;

    —  wishes the timing of determinations to be more appropriate.


  11.1  If the Government wishes to end post-code prescribing so that all of similar need should have access to similar treatments around the country, then:

    —  specific funding needs to be provided to fully fund NICE guidance;

    —  prioritisation of what NICE examines is crucial now that guidance is binding. Drugs or interventions should be chosen as those most likely to meet major needs rather than those which, for instance, pharmaceutical companies are about to produce. The selection process needs to widely involve healthcare commissioners, providers and patients;

    —  there should be recognition of the need to prioritise local needs for health economies which have significant health problems.

  11.2  If the Government wishes to allow new technologies or drugs to be funded by the NHS until they have been found to be sufficiently effective and appropriate then:

    —  No drugs or technologies turned down by NICE may be used in the NHS; but

    —  Guidance on those technologies which are recommended by NICE can be used locally as guidance, but the determinations should not override local assessment of what is most important to patients and to meet local needs.

  11.3  If the Government wishes to use NICE to appraise new interventions about to diffuse into practice:

    —  The determinations need to be available before the interventions have actually diffused into practise.

    —  For new drugs this may mean that they are formally "on approval" or given a provisional NHS funding approval in possibly selected centres, until determination is available; or

    —  For new technologies, they are only carried out selectively at specific approved centres until determination

  11.4  A compromise position which would allow the Government rightly to end postcode prescribing of essential treatments but would allow some local discretion in funding priorities would involve:

    —  A limited number of determinations would be very carefully chosen as vital to the population's health.

    —  The process would be very important and should be explicit and the responsibility of DH, not NICE. It would need to involve providers, commissioners and patients. There may have to be a maximum number of such interventions or maximum total proportion of a notional PCT budget which would be likely to be represented by these drugs in total.

    —  Funding these interventions would be mandatory, regardless of where patients live.

    —  Other guidelines/determinations would be used locally in decision-making processes but their use would not be binding.

  11.5  Our main recommendation is that if the government wants a single national focus and wishes guidance to be owned and implemented consistently, then NICE recommendations will have to be priced appropriately and come with full earmarked funding to allow local commissioners to meet local needs without distorting existing priorities and to allow for differential needs to be addressed.

January 2002

2   Raftery J NICE: faster access to modern treatments? Analysis of guidance on health technologies. Back

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