Select Committee on Health Minutes of Evidence


Examination of Witnesses (Questions 200 - 210)

WEDNESDAY 23 JANUARY 2002

DR TIM CRAYFORD, HELEN MARLOW, DR DEIRDRE CUNNINGHAM AND DR DAVID WALKER

  200. But it is a National Health Service. Why should somebody in Inverness, for example, have different prospects or limitations from somebody in Plymouth?
  (Dr Walker) If you take the Relenza issue again, if you want to have a drug out to people within 36 hours of them starting their symptoms, in an urban centre like London, that is very simple to do. There is a pharmacy on every corner and a GP within ten minutes. In rural Northumberland it might be an hour's drive or two hour's walk or a whole day on public transport to get to your GP. It is not practical to have mechanisms in place to give access to that drug to everybody in rural Northumberland. There are differences. Also, as we heard before, patterns of disease are different. Psychosis might be a big problem in central London, but we have problems with respiratory disease and cancer in the North East. There is a funding issue there about differential funding and also how the funding is distributed once it is decided whether it is going to be a per capita basis or a per case basis. For example, some of the money allocated for NICE drugs in the country is allocated to trusts as a standard uplift percentage on the allocation every year, but different trusts will have different amounts of need for NICE related drugs. Cancer centres may be based in some trusts who will get the same uplift as general hospitals with no cancer centres and yet they will have to spend a lot more of their uplift on those NICE drugs. There are differences between localities.

  201. I can tell you psychosis is certainly a problem in this part of central London. The other point you raise regarding setting priorities is that "... local health authorities, who are required to ensure the implementation of the guidance, are unlikely to be consulted".
  (Dr Walker) Yes.

  202. I do not fully understand the conditionality in that assertion.
  (Dr Walker) The NICE process does allow for consultation of health authorities but it is unlikely to be yours. At the moment it is unlikely that every health authority is going to be consulted about a particular issue. What I should like to see is commissioning bodies, PCTs, in the future having the option to take part in the process and to comment on the process and feed into the process if it is an issue for them or they have a particular issue to raise.

  203. What problems would it avoid that you are currently experiencing with health authorities' work. You are seeking a virtually mandatory inclusion.
  (Dr Walker) It would affect the prioritisation first of all, the selection of products or technologies to be appraised, but it would also take account of the difficulties in implementing the guidance, the practical difficulties we mentioned before. Both of those ends are not fully addressed by the process at the moment.

Chairman

  204. Picking up your point and wrestling with the issue you have all raised with us of how you determine what you should spend a limited amount of money on in your locality, one of the issues I put to witnesses last week was whether you have any ideas as to how we may move in a radically different direction involving, engaging with the local population and ensuring that the local population in your area is consulted where there are different views and different priorities and different experiences. I am familiar with your area Dr Cunningham and I understand the point you are making about 155 psychosis. Is there a way in the process of devolving decision making, which the Government say they are moving towards, of actually engaging with the population on the kind of issues you wrestle with?
  (Dr Cunningham) Quite a lot of us have had experience of doing that before NICE came along. We have various ways of consulting with the local population about where the resources should go, including things like citizens' juries in Lewisham and health panels and now primary groups and primary care trusts have their own ways of consulting with the public. I think the problem we are all facing is whether NICE guidance is absolutely binding, whether somebody with something in the north of England should get exactly the same treatment as somebody in the south of England. We all recognise the problem that we want to avoid post-code prescribing and that maybe there may be a limited list of things which everybody has to get all round the country. Even if we were all widely involved in the NICE consultation, if you said respiratory disease and you said psychosis and NICE were supposed to make sense of that, what would they do? I do not know. It means we have to have local discretion, we have to involve people. I know there are lots of moves from the Government to involve people and primary care trusts are where a lot of it will happen.
  (Dr Crayford) There might be some circumstances where NICE's guidance should be mandatory, where there are not large national variations between the north and south of the country or inner urban areas where post-code prescribing is irrational. You might include beta-interferon on that but a national statement about beta-interferon could be quite helpful. Where there are local concentrations of disease, then that does not fit in with local priority setting.

Dr Naysmith

  205. Just going back to Dr Walker's submission, we talked about local health authorities being unlikely to be consulted. Very importantly you said you had no right of appeal against draft appraisal where other people do.
  (Dr Walker) Yes.

  206. How important do you feel that is?
  (Dr Walker) There have been relatively few occasions when it has been important. With the issue now of guidance being mandatory effectively and more and more appraisals and this is going to represent a larger and larger budget and a decreasing amount of flexibility with which we have to deal with local health problems, it becomes a bigger issue and there will be occasions for individual health authorities wanting to contest or add information to NICE appraisals. At the moment there is no way of doing that.

  207. There is no mechanism at all at the moment for doing that.
  (Dr Walker) You can feed information back to NICE but it is not part of the formal process.

  208. Do you feel strongly about it too?
  (Ms Marlow) A director of NICE at a conference I attended was asked whether, if we felt strongly about a particular guidance, we could appeal against it and we were told no. I feel that does not really help in terms of ownership of the guidance.
  (Dr Crayford) So in terms of improving NICE's process, one is greater inclusiveness. Another idea is to make NICE more financially accountable. At the moment NICE produces guidance but it does not assume any financial responsibility for that; we have to at health authorities. If NICE were to have a discrete budget to work within, it would then make more sense of how it prioritised, what sort of advice to evaluate.

  209. Do you think they work too much in an ivory tower? Is that the problem?
  (Dr Crayford) Yes.

  210. You are where the problems really are. Is it giving advice which is theoretical?
  (Dr Crayford) It is about how it considers the issues that we should like to see. I should like to see NICE evaluate the value of the nurses we need in our accident and emergency department and it does not do that. It considers treatments which are important, of public interest, which might not necessarily fit with the overall prioritisation process of the NHS as a whole.

  Chairman: May I thank our witnesses for a very useful session. We are very grateful for your co-operation.





 
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