Select Committee on Health Minutes of Evidence


Examination of Witnesses (Questions 220 - 239)

WEDNESDAY 23 JANUARY 2002

MR EDDIE GRAY, MR HUGH MCKINNEY, MR DAVID CAMPBELL-MORRISON, DR TREVOR JONES, MR BILL FULLAGAR AND DR JOHN PATTERSON

  220. To take part in that evaluation process. There is no other means whereby this independence is compromised by your industry.
  (Dr Jones) We have had a regular dialogue with NICE, as have others; the patients involved in NICE and so on. That has been part of a very open process which emerged from the Prime Minister's initiative on competitiveness where we defined quite clearly with Ministers, with the endorsement of the Prime Minister the process to try to discuss together how we would improve the process of selection and how we would get through the process of appraisal. That has been a very productive dialogue and one we think is resulting in significant progress. We do not see that as any kind of bad way of working together, it is a very productive way in the interests of the patients and the National Health Service and the industry.

  221. You heard the evidence in the previous session which related to vested interests being within NICE. What was meant by that?
  (Mr Fullagar) I wish I knew. I share very strongly the answer you have heard from my colleagues. As far as my company is concerned, we respond. We were specifically invited to answer questions which are set down by NICE, quite rightly. The only other contact with NICE of which I am aware is when we talk to them about the process in a very open way as other people do to get the job done, not in any way steering decisions; I am totally unaware of anything else.
  (Dr Patterson) The last group of witnesses called for people to state any conflicts of interests they may have. We would have no objection to that at all.

Sandra Gidley

  222. Some questions for Mr McKinney and Mr Campbell-Morrison from the Campaign for Effective and Rational Treatment. You make some comments about transparency in your submission. Could you explain the relationship between your organisation and the pharmaceutical industry and NICE so that it is on the record?
  (Mr McKinney) CERT is set up that we come up with a proposal that we think needs to be addressed within health care issues, usually in a drug sense. We are looking at better and more equitable access to drugs. We then go to the pharmaceutical companies and say "Here is the proposal. Here is what we are trying to achieve. If you support this then finance it. If you don't support it then don't finance it". In effect it is fairly similar to a charity. No matter how much money they decide to give us they have no rights over the direction we take or over the policy we take. We decide what the outcomes are, we decide the methods by which we achieve those outcomes and the pharmaceutical companies have no say in how we achieve what we are trying to achieve. We do keep them informed of what we are doing because they are helping to finance this.

  223. I am not quite clear on how you make sure there is impartiality here. You are saying you have a proposal and you tout around the drug companies until you find somebody who likes what you have.
  (Mr McKinney) Yes. We discuss with our steering committee, made up of medical clinicians, what the issues will be in the Health Service, usually on quality of access to treatment, to drugs. Then we prepare the proposal designed to try to make sure people do have access to these drugs. Then we say to the pharmaceutical companies that this is what we are trying to achieve, if they agree then they should support it.

  224. Would you then be under any sort of pressure to adapt the process?
  (Mr McKinney) We do not. We say this is what we are doing: accept it or do not accept it.
  (Mr Campbell-Morrison) The team doctors would approve that method of getting those objectives. For instance, in our cancer programme we used a template produced by Max Somerhayes and the National Cancer Director when he was at St Thomas's. We adopted that template which worked out the number of people who would be eligible for treatment and then worked out a total for all the different treatments which were looked at and extrapolated that nationally. Then we got an eminent team of oncologists who would look at the proposal and say "No, this estimate is too high", or too low or not a priority in cancer treatment.

  225. You are very critical of almost all aspects of NICE. It has been running for almost two years. You are also quite clear on the point that any credible assessment body must be separate from the Government, which puts you at odds with the submissions we have had from the ABPI and GlaxoSmithKline. Do you think the fact that Alan Milburn announced last week that he was not going to sign off the proposals in future will make the slightest bit of difference?
  (Mr McKinney) Can we put that a slightly different way and go back a bit on that? It comes back to the question initially asked about independence. We feel that with the status of a special health authority which is run in effect by career civil servants from within the NHS and as a body working from the NHS that is the basis on which we question the independence of NICE. Although we have been critical of all aspects of NICE, we should provide a caveat and say that we do support the concept of NICE. We did not actually mean to be critical of every aspect, but the more we looked into it, and the more we asked doctors, the more we asked clinicians, the more we asked consultants, the more we asked patient groups the worse it got. This is an objective third party representation of all the difficulties which were represented to us of NICE. That is how we arrived at that position, not because we sat down saying everything about NICE is wrong so let us try to tell people what is wrong with NICE. It was the way it happened: people came to us when we looked into this and that is perhaps why we have been seen to be so critical.

  226. Is not the problem that if you remove it from Government control they would basically be all over the place because there would be no co-ordination with national priorities for health. I cannot quite see how that would work. Can you explain to me a little bit more about how you would change the systems so that it would be better overall.
  (Mr McKinney) We call for the independence of NICE in our submission on personnel within NICE. Rather than using career civil servants, we said we should look at other methods of doing this, we should look to some of the experts abroad, we should look at some of the other objective

experts we have in the UK. Rather than rely on civil servants to run it, let us use the experts to run it. That is the sense in which we mean independence on that.

  (Mr Campbell-Morrison) Going back to questions raised last week, one of the questions was whether NICE is a form of rationing. What we have to look at is that drugs are licensed in the UK through the MCA or the EMEA. Drugs come onto the market already proven safe and efficacious. The only thing NICE could possibly add is this element of whether the drug is worth it, whether it is worthwhile introducing in the NHS. In that case, it should be explicit that this is a rationing body and what Hugh is saying about career civil servants is that if they—excuses to civil servants in the room—go against the policy line within the Department of Health, their career is not going to be worth very much. It is important to set up NICE as a corporate body, to have physicians, to have health economists and we need ethicists within that body to look at it. It should be as independent as possible from the Department of Health. That is the crux of the matter there.

Mr Burns

  227. You have been very critical in certain aspects of NICE and in your submission one of the things you have been critical about is what you describe as the unplanned and unexplained delays in some of the appraisals by NICE. I should like to read you the rest of that paragraph of your submission. You say, "For instance, the appraisal of Herceptin has been inexplicably delayed by six months, even though this drug can have a dramatic effect on the survival of women who have an aggressive form of breast cancer". That is quite a serious suggestion. You then go on at the end of that paragraph to ask a question. "How many women with breast cancer have died prematurely as a result of this delay alone?". I should like to ask whether you know the answer to that question.
  (Mr McKinney) The simple answer is that we do not. We have posed the question on the process of NICE, to say this is the problem with the delay and we are asking how many people have died. We cannot believe they have not, because of the undue delay in the appeals process for this and it is mirrored later on in the colorectal drugs as well. We ask because of this delay—we are raising the question for general debate—how many people have died. It is perhaps not a question for us and maybe we should not have asked it in that form.

  228. Only you have posed the question.
  (Mr McKinney) Yes, we are entering into the debate to ask how many people have died.

Chairman

  229. It is a pretty serious allegation you are making. Do you stand by that completely?
  (Mr McKinney) Yes.

  230. Categorically you think it is fairly convincing that because of the delay, even if you do not know the numbers, there will be some people who have sadly died who otherwise may not have died in that delayed time period because this drug had not received its appraisal by NICE.
  (Mr McKinney) Yes; we think unquestionably.
  (Mr Campbell-Morrison) Yes.
  (Mr Fullagar) I did ask the company which makes the product what estimates they make of this. They say that in their estimates there are 5,000 women a year who would benefit from this treatment theoretically. Since the product has been in place with its licence since September of the year 2000, they have a figure of less than 200 patients treated with the product out of a theoretical population of 5,000 and they say that the majority of use is by private patients, so not funded by the Health Service. This they produced for me figures from other European countries, big and small, showing that in fact the use was much higher than the UK, up to eight times higher.

  231. Are you saying that the benefit of the use of this drug would be that the individual patients would live longer as a result of taking the drug, or that they would not die at all because of the drug?
  (Mr Fullagar) The claim is that they would certainly live longer and live a better quality of life as well. For whatever reasons the process has still not ended, although the product has been available with a licence since September of 2000.

  232. Mr McKinney, am I right in thinking that a minute or two ago you said you had raised this matter with NICE?
  (Mr McKinney) No.

  233. You did not raise this specifically.
  (Mr McKinney) Not as a specific issue, no.
  (Mr Campbell-Morrison) It is possible to test whether a patient is going to respond to this treatment. With most treatments they have what is called a median survival time. What NICE is looking for in the cancer field is whether a patient is going to live at least an extra three months. What happens with this drug is that you test people, so you are excluding the people who will not respond to it. Certainly from the people I know who have been on it, the response has been quite fantastic. I know a senior executive who had possibly one month to live and she has been on this drug and she is now still working about two and a half years after she should have been dead.

  234. Do we know roughly what the cost of a course of this drug treatment is?
  (Mr Campbell-Morrison) I am afraid I do not know. There are various estimations. What happens is that when the drug is licensed there are negotiations with the NHS for what is called the NHS list price. Often what happens is that companies will make negotiations with local health authorities that the price will be much lower than that.

  235. Obviously I do not have a clue what this drug may or may not cost but the rough figure for what it costs per patient for Beta-interferon a year is about £10,000. Whether that is correct or not is another matter but that is the kind of price tag which is bandied around. Is there any similar sort of price tag bandied around for this drug?
  (Mr Campbell-Morrison) At a guess, if you will accept that, it is approximately £15,000 per year. The public health people previously said that a benchmark figure for quality adjusted life year is around about £30,000. They will put somebody on the statin drugs to prevent a heart attack and that is the figure they will use there. The quality adjusted life year is approximately £15,000 so it is well below that.

Dr Naysmith

  236. Is there no other treatment at all for this condition?
  (Mr Campbell-Morrison) No. It is for a sub-set of patients who have what is called a Her-2 marker on the tumour.

  237. What would happen to these patients if this drug were not available?
  (Mr Campbell-Morrison) They die. It is very aggressive.

  238. There would be no treatment at all.
  (Mr Campbell-Morrison) There are the cyto-toxic treatments which you would use possibly by themselves or in conjunction with a drug, an antibody, but usually it is reserved for people who have no active choices to make.

  239. There are other treatments but not for this particular sub-cohort of the population.
  (Mr Campbell-Morrison) Yes.


 
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