Examination of Witnesses (Questions 180
WEDNESDAY 23 JANUARY 2002
180. You are acting as a mouthpiece for those
(Dr Walker) Yes.
181. That is fine. That is just what I wanted
(Dr Cunningham) I am in exactly the same position.
I do not want to major on the quality of the guidance, because
I am not necessarily an expert in guidance. Certainly what we
have is very much better than what we had before, which was that
we had to do it ourselves. We set up local expert teams and around
London you might have had ten different expert teams doing the
same sort of appraisals. What we have is very much better. We
do have some difference. When we look at NICE guidance which comes
out, we have some differences of opinion, for instance we have
already mentioned that the cancer collaborative network had already
done a lot of work with clinicians all over London, looking at
the range and quality of the literature, rating them on strength
of evidence, possibly with slightly more health economic data
than has been possible to include in some of the NICE guidance.
The example where we should have liked slightly more health economic
data was Docetaxel for lung cancer. There are slight differences
which we might quibble about but basically we very much welcome
the fact that there is national robust guidance that we do not
all have to re-invent the wheel everywhere. Obviously when guidance
comes out, I chair the area prescribing committee which has all
the pharmaceutical advisers on it from our local trusts and primary
care groups and trusts. It has clinicians, it has academics, it
has chief executives of the primary care groups and trusts, it
has a lot of people on it. We crawl over it but we really do not
think we ought to re-invent the wheel here.
182. A very quick comment. There are public
health doctors and public health doctors. I shall not say any
more than that. What I should like to draw attention to is Dr
Crayford's very good illustration. You gave us the figures and
I think the press should be aware of these: four implantable cardiac
defibrillators cost £120,000 and for that same amount of
money you could have funded four extra nurses.
(Dr Crayford) Yes, around that.
183. That is staggering and that absolutely
shows the problems you are faced with of prioritisation when these
are put on top of you.
(Dr Crayford) Exactly.
184. That is really almost the most important
message we have so far. Another very quick message to underline
is the ethical input which Dr Cunningham implied was lacking.
I should love that to go forward. A question: Dr Crayford is very
keen on the "not recommended" advice. Do you have advice
for how NICE really should be working? How it should relate possibly
to the BNF, which is a very authoritative statement of treatments
which should be used?
(Dr Crayford) Yes. The relationship between the introduction
of a drug and its licensing, its appearance in the BNF for doctors
to prescribe and then guidance associated with its use really
needs to go hand in hand and there needs to be much closer inter-connectiveness
with NICE and the drugs licensing procedure. That will stop some
of the planning blight. Turning to the second part of the question,
I have brought along a list of some of the priorities we have
had to consider this year in Croydon as a result of the many national
initiatives through national service frameworks, through the local
modernisation review, which have resulted in bids of £70
million, when we are likely to have as a health authority somewhere
between £6 million and £11 million to spend on some
of these things. We have to go through a prioritisation and filtering
process which weighs up all of these priorities and this is where
the issue of implantable cardiac defibrillators is key. The nurses
we could put into accident and emergency very directly stack up
against some of the things which NICE have funded. When NICE says
yes and it is mandatory, it deprives our local residents of the
chance of getting core and basic services. Coming back to the
point when NICE says no, we have this list of 450 things which
we could fund and frankly we do not need a lot more help to say
yes to particular interventions, which is often where NICE has
come down; NICE has not actually said no. We need help with saying
no and with the filtering out process. One of the things NICE
has is a standard of cost effectiveness which it attempts to use
to decide whether or not to recommend a treatment which is £30,000
per quality adjusted life year. If you will forgive the technicality,
that allows a consideration of one treatment against another.
There is a real question about where that level has been set,
if it is letting things under the wire such as implantable cardiac
defibrillators. NICE is very helpful to us when it says no; the
trouble is that it does not say it very often. Secondly, where
it places its line of when it allows a drug through or not is
also quite questionable.
(Ms Marlow) I am not quite sure of the line of your
question but you talked about how NICE should be working. There
is a key point about NICE trying to get closer to those who are
involved practically in implementing the guidance and getting
more feedback about how it is working, how it can be improved,
made more user friendly. At the moment there is a bit of a gap
there between NICE and the constituents, particularly primary
care and GPs.
(Dr Cunningham) We would completely endorse that.
We in our health authority have exactly the same problem as Dr
Crayford has and I imagine Dr Walker has but we have far too many
things to do which are very important and we cannot even meet
the Government's top 20 priorities; we cannot even fund those
easily. There are some things like emergency care, getting people
into hospitals, reducing waiting times, some of these things which
the public think are very important but we shall not necessarily
be able to do if we have to fund these things fully. If we have
to fund them fully we really want to be very involved in the debate;
first of all the selection, what they are going to do; secondly
how they consider them and how they consider them as part of a
systems' approach and how easy they are to implement locally and
all the other things you have to do locally as well as provide
a drug. Lots of guidance comes out where you have to do quite
a lot of other things locally. Primary care has quite a large
capacity problem to implement these.
185. Did I hear you say that you feared that
things like bringing down waiting lists could be adversely affected?
(Dr Cunningham) The Government has given an increased
uplift to the NHS but it has also given increased targets which
the NHS has to work to which all the public and everybody is well
aware of. We are required to concentrate on trying to meet those
targets. The national planning guidance says in the guidance that
we have to meet the NICE guidance requirements in cancer. It does
not actually say in the planning guidance that we have to meet
the rest of NICE requirements; that is part of a separate guidance.
We are struggling in our health authority because we have a huge
burden of problems to meet the Government's emergency care and
other top priority targets. This requires resource investment
and we are having to make exactly the choice that Dr Crayford
talked about, whether we invest, what we need to do to meet these
targets or whether we fully fund some of the NICE guidance which
may be slightly less of a priority locally.
186. What conclusion have you reached in answering
(Dr Cunningham) We thought it was a sacking offence
not to meet the Government's top 20 priorities.
187. Presumably that would suggest that if you
have problems now, when the 15-month target comes in on 1 April
you are going to have even more problems.
(Dr Cunningham) Yes.
188. Are you not confident that you will meet
that target, so there may be sackings?
(Dr Cunningham) No; I will not be drawn into that.
Obviously we are putting all our efforts into trying to meet these
targets locally because we know that is what is required and we
are trying to do that. What that means is that we have to concentrate
our efforts on those things which will enable us to meet those
targets. We also have to concentrate our resources on what will
enable us to meet those targets. I do not say we have a problem
in meeting the targets, but I do say if we have lots of other
priorities coming down as well as these top 20 priorities, then
we are going to have problems.
Dr Taylor: Several of you have said NICE guidelines
are mandatory. We rather got the impression last week that that
was changing although in the House in debates in July and August
Yvette Cooper said they were. One of our witnesses last week at
least said that that was changing. Is that anybody else's memory?
189. No; I thought it was the other way and
they are becoming more mandatory.
(Ms Marlow) There was a statutory instrument just
before Christmas which made it mandatory.
190. Dr Cunningham, you say that there is a
tension between "national guidance and local need" and
you have skirted around and elaborated in part on that in earlier
questions. Do you think this is inevitable? What do you think
NICE could do to avoid it or could have done to avoid it or minimise
(Dr Cunningham) When NICE was set up I did not think
it was necessarily the Government's intention to make all of NICE
guidance binding, so the way NICE chose what it was to look at
was not geared up to best meeting the needs of local populations.
Some populations have different needs from others. For instance,
I come from a population which has in some parts, in the Southwark
primary care group, six times the level of psychosis in some of
its neighbourhoods compared with the national average. When NICE
was set up we thought we would be getting guidance over which
we had discretion locally, for instance if we have a huge sexual
health epidemic, which we do, a huge burden of mental health disease
and maybe not so much in the other areas like cancer. About three
quarters of NICE guidance in terms of financial consequence to
the NHS appears to relate to cancer and cancer is not as big a
problem locally as psychosis might be. When we thought we were
getting the guidance, if we had had discretion locally to use
the guidance in some areas more than others, that would have been
fine. Our problem comes if we do consider that it is binding and
we have to fully fund it after three months, it distorts local
priorities. It would also not be a problem if it came with funding.
If the Government said that NICE guidance was binding and they
wanted everyone with the same condition, same need to have the
same treatment around the country, that would be fine if places
which had a lot of people with those needs got funded more than
other places. That, however, does not appear to happen. Also,
it would be better if we could influence what they do so that
our needs could be their needs, so they could actually consider
those areas we have most problems with locally.
191. On a number of occasions you have said
during the course of your answers that you have a problem of limited
fundsI suspect this is not confined simply to you. If there
is a drug which you consider is a poor product or you believe
it is out of date in its effectiveness clinically, why do you
not think you should be able to give local practitioners advice
against implementing the NICE recommendations?
(Dr Cunningham) Did I say that?
192. No, what you said was that you had limited
funds and it was a question of juggling priorities.
(Dr Cunningham) This is indeed what we did before.
193. What I am asking is whether, if NICE in
effect recommended a product which you think is a poor product
or that it is out of date and there are better drugs on the market
(Dr Cunningham) Or of less value; yes.
194. Why do you think you should not be able
to make recommendations to GPs that they do not take the NICE
(Dr Cunningham) That is exactly what we were doing
before the latest.
195. Exactly. But now, with the latest.
(Dr Cunningham) That is exactly what we were doing.
We would consider the guidance in our prescribing committee, which
has representation from GPs, clinicians, primary care groups,
hospital trusts, mental health trusts, everybody. We would consider
the level of benefit we thought would be achieved for our local
population and the level of benefit which would be achieved even
when NICE said yes for individuals, we would consider all the
other calls on our resources and how much of this we wanted implemented.
One good example is statins for secondary prevention of heart
attacks. We felt that this was a valid use of resources and we
encouraged GPs to do it, but in terms of primary prevention we
did not feel we had enough money and the six primary care groups
had actively discouraged its use for that time. What we are now
told is that we have to implement the guidance, which makes it
a little difficult for us to advise individual clinicians not
to prescribe it. We have taken advice from the lawyers on what
the position of an individual clinician might be, or a manager,
if they had a patient in front of them who said, "The NICE
guidelines say this treatment is appropriate for me. Are you going
to prescribe it?", they say no and it puts them in a rather
difficult position as far as clinical governance, clinical standards
are concerned and the patient.
196. As a matter of interest, because I genuinely
do not know the answer to this, what happens in the light of the
changes you have just described if a drug does become out of date?
Is there some way that you or the medical profession can go to
NICE to point out that their advice has become outdated and is
no longer relevant or maybe not the best advice? Or, can it only
be done through Ministers referring another item to NICE to consider?
(Dr Cunningham) We do already talk to NICE. We have
talked to NICE about the affordability issue. We would feel able
to make our views known to NICE, whether or not it was part of
the formal process.
(Dr Crayford) NICE's guidance is time limited so each
piece of guidance is scheduled for review after a certain period
of time depending on the technology. Usually it would be fairly
197. Since our meeting last week we have had
guidance from one of the experts we had last week that there are
in fact two examples where a health authority or a PCT can advise
against NICE guidelines. The first one is if the authority has
legitimate and well-founded reasons to think that the guidance
is mistaken. The second is that the health authority or PCT may
say that it has insufficient funds to accommodate NICE guidance
and does not want to divert resources away from its own projects.
Those are two examples that we do have.
(Dr Crayford) In relation to legal advice, it is a
side issue to the central issue of NICE, but it is expensive for
the NHS. Health authorities and PCTs across the country are now
independently going and consulting their lawyers about what to
do with NICE guidance, how to implement it, whether to implement
it, individual clinical cases. It is very expensive seeking medico-legal
advice and usually the same firms of lawyers are giving the same
advice to all of our different authorities. It really would be
very helpful if NICE provided legal advice to the NHS about the
legal implications of its guidance.
198. You still go to you solicitor to try to
get a different view though.
(Dr Crayford) I am not sure we would.
199. Dr Walker, you said in your submission
that because of the challenges NICE is facing, priority setting
is a key issue for the future. Who do you think ought to be setting
those priorities and who ought to be involved in considering them?
(Dr Walker) It has to be a broad-based approach, but
it has to be very inclusive and take account particularly of local
priorities. This point has been raised before, that a one-size-fits-all
approach is good in that it gets rid of post-code prescribing,
but it can be unhelpful and it can limit flexibility locally and
there needs to be some trade-off for that and local problems and
local specific factors need to be taken into account in the priority