Select Committee on Health Minutes of Evidence

Examination of Witnesses (Questions 260 - 279)



  260. So you are not criticising NICE per se in terms of the Appraisal Committee. You are saying that some of the contracts they give out to various other institutions or people are not of high enough standard. Is that it?
  (Mr Gray) Certainly where we touch the process we see a high level of factual error and we are aware from a recruitment point of view that NICE recognise the problem themselves.

  261. Would you be prepared to name any of the recent appraisals which have fallen into that category?
  (Mr Gray) Pretty much factual errors of varying degree have occurred in all of the individual appraisals which we have been involved in. An example would be in a diabetes treatment where the original assessment included commentary about use of the product on its own with patients, not in combination with any other products. That is actually outside of the licence indication. We were able to point that out and it was changed. That would be one example.

  262. Do you think this whole business has seriously affected NICE's judgements? What proportion of the reports would you say this applied to, or is it just one or two?
  (Mr Gray) Clearly as the process has developed, and we should say that the degree of openness of the process has improved over time, therefore our ability to assist the assessment groups in identifying these kinds of errors has improved over time. As I also said at the beginning of my answer, we do not have a question about the quality of the individual on the Appraisal Committee itself, but it is very difficult to follow through and give you a percentage of occasions on which it comes up with a poor answer in that case. In terms of our own experience, we do have areas such as the example I gave, where even though we caught that particular issue with the indication, once we got to the end of the process, in our view we would still feel that the guidance was unclear by the time it was finished. That is about as much as I could say.

  263. The other thing you suggest is that the industry itself should be involved in the selection of treatments and procedures and drugs which are looked at by NICE. Do you think that is important?
  (Mr Gray) I think it is important that all stakeholders are involved.

  264. How would it help?
  (Mr Gray) We had an eloquent answer to that from the last set of witnesses about how really the identification of NICE's workload needs to be better allied to the challenges which the National Health Service faces. If that is the case, then the process of setting NICE's workload really should have the input of all groups who can make a contribution. I did notice that NICE itself have put their own submission to this Committee on their website and I notice that they are calling for that themselves. They have identified, as did the last group of witnesses, that people who work in the National Health Service should be involved. Similarly we would feel ourselves and patient groups and expert groups, Royal College of General Practitioners, whatever, are all valuable people who can help understand the balance of challenges that the NHS face and particularly if there is a focus on guidance and not appraisal which areas are likely to bring the greatest benefit.

  265. Is that something which is shared with the industry as a whole?
  (Dr Jones) Very much so.

  266. Would they like to be able to be involved in what is submitted?
  (Dr Jones) All the stakeholders involved ought to be part of a transparent process there.

  267. Of selection?
  (Dr Jones) Yes, of selection of the priorities which need to be identified.

  268. Would ABPI do that?
  (Dr Jones) We could offer an individual or individuals who could represent the wider view of the industry to do that. That said, over the years some of us have sat in areas and represented industry although we wear a particular company tag. For 12 years I was a member of the Medicines Commission. I do not think in any way that gave me a bias because of where I was at the time. We can do that in an objective way with all the declarations of interest on the table.
  (Mr Gray) I have not actually seen it in full myself but I understand that the Department did announce yesterday that they were going to issue a consultation document on this very point which GlaxoSmithKline would certainly welcome and would look forward to making a constructive contribution to that.

Andy Burnham

  269. I note that the ABPI's evidence does actually say that you have been involved in discussions with the Department and NICE about the process for the selection of topics. Are we right to conclude that it is already happening?
  (Dr Jones) We have had very constructive discussions on that following the endorsement of the Prime Minister about working together generally. We have made submissions to them. We understand from the statements recently that there will be some consultation now by NICE on this issue. We look forward to seeing that consultation. Hopefully it will reflect many of the discussions we have had very openly with them in the last six or nine months.

  270. Do you feel the direction is going that way?
  (Dr Jones) Indeed. For example, we welcome the statements the Secretary of State made last week on the response to the Kennedy issues; the point made about independence earlier. It is pragmatically necessary to have this link somehow to the Department of Health and the National Health Service. NICE became some isolated body, it is just not going to be tied into the overall system. The idea that the Secretary of State has mooted, that it has more independence and direction in its own activities, is very welcome. Yes, this dialogue has been very productive. We have put our proposals and we look forward to seeing the consultation document which I believe will come out shortly.

  271. Would you welcome patients being as involved in that process as others?
  (Dr Jones) There is a group called Patients Involved in NICE (PIN) who also have regular dialogue.
  (Dr Patterson) Patients, health providers, primary care physicians should all have input.

  272. PCTs.
  (Dr Patterson) The point we want to make is about the selection of technologies (for assessment) rather than guidelines. You cannot simply take a technology at launch, (ie a new medicine), and always be able to do the work which gives you the definitive answer. If it is a medicine which is in a well trodden area of medicine like diabetes or asthma, you might well have the kind of information you need to make cost effectiveness measures. However, if you have a brand new treatment for Alzheimer's for instance where there is nothing else that works and it is a difficult area to measure, it is going to take some while of usage in real life to establish cost effectiveness which takes availability in the health system to achieve. We are in danger of a Catch 22. If all the medicines are assessed at launch, a large number of them, or interesting ones, may well not get through. You have heard already that if they do not get through, they will not be prescribed, they will not get onto formularies, so we will lose some really useful medicines.

  273. How do you balance the tensions within your own organisation about which technologies get put forward? Is that difficult? Can you always give an impartial view? Obviously there are competing pressures there, are there not?
  (Dr Patterson) We all have competing pressures in our own organisations and we make priority decisions.


  274. There are competing pressures in this place, I can tell you.
  (Mr Campbell-Morrison) I should like to go to some points raised by Mr Gray and the public health doctors about the issue of funding and priority, for instance we are very involved with cancer drugs at the moment. The Government has been very generous in the present financial year, in the region of £258 million allocated for new treatments in cancer and we really do not think that is being fed through. It is very difficult with the financial systems to see what that is actually being spent on. Talking to oncologists, it appears that has not reached the oncology unit, it has been used for pressures in other parts of the system. A partial answer to the public health doctors is that the money allocated by the Government for cancer treatments should be used for cancer treatment as far as possible.

  Chairman: Mr Burns has noted that you have said the Government has been very generous.

Sandra Gidley

  275. It has more or less been covered but back to Mr Gray. You have been arguing in your submission for full disclosure of the membership of the Technical Advisory Group and there have been many submissions around transparency, also for disclosure of level of industry representation. Who else should be involved in decisions about NICE's agenda?
  (Mr Gray) Clearly we would agree with the submission that patient groups and patient representatives will be involved. Local health care areas, be it PCTs or whatever, would seem again to have a strong contribution to make, as indeed may some of the professional bodies: Royal College of General Practitioners, other expert groups.

  276. Let me play Devil's Advocate for a moment. We all say yes, this is nice and fluffy and consultation is the thing to do. I agree, but it takes time.
  (Mr Gray) It does.

  277. The longer you take over a consultation, the longer people are waiting for medicine. Where is that balance?
  (Mr Gray) That is one of the reasons why we feel that the emphasis on medicine or technology appraisal is letting down NICE's track record. Actually a concentration on the provision of guidelines and best practice within which PCOs, PCTs, individual clinicians, could start to work with the available medicines and technologies to achieve those goals, is much more likely to produce the outcome that NICE and everybody else is looking for. Obviously once one starts to look at different therapeutic areas and different diseases, there are far fewer of them than there are individual medicines and individual technologies. That in itself should help the issue of workload and how much success NICE is likely to have. The other benefit is indeed that local primary care organisations or local clinicians are then less likely to perceive an either/or in areas where clear guidance is provided by NICE about what is best practice. They can work with their individual patients to try to achieve those goals. In areas where there is not yet NICE guidance, there is not really a situation where clinicians or primary care organisations would say they are not doing that until there is a NICE recommendation. Clearly if there is no NICE recommendation for psoriasis, the GP is not going to tell the patient to wait and come back when NICE have decided on psoriasis. They will use their clinical judgement experience to deal with that patient in much the same way they do now. Our submission would be that that move in concentration towards the guidelines and away from the appraisal process helps NICE in many ways.

  278. Then the other things will automatically come on board, such as the patient's input.
  (Mr Gray) Exactly.

Dr Taylor

  279. May I just go back a step, because we have missed something out on breast cancer? If the evidence is so incontrovertible about this

particular drug, why are the oncologists not all jumping up and down, or are they?

  (Mr Campbell-Morrison) They are.
  (Mr McKinney) They are.

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