Examination of Witnesses (Questions 500
WEDNESDAY 6 MARCH 2002
HEATH OBE AND
500. One of the intentions as much as anything
is the wish to have a National Health Service and national guidelines
on the one side and then to have on the other side people locally
owning plans and policies. NICE is only going to be successful
if that is achieved. At the moment we hear stories of individual
clinicians saying, "Oh, well, NICE has recommended this but
I do not agree with it", so they are recommending a different
treatment for the patient and that is obviously undermining NICE
and making patients very confused. In your view how successful
has NICE been in trying to establish that local ownership and
do you have any other ways of trying to further that?
(Lord Hunt of Kings Heath) I think you have raised
a very important point. I make no apologies for the fact that
some of the actions we are taking in relation to NICE and the
national service frameworks on the question of health improvement
are trying to get national consistency through the NHS. I think
that is entirely justifiable. Anyone who has worked within the
NHS will know that that will only be successful provided you also
give enough space to people locally to manage the Health Service
and that they do feel some ownership. I agree that we need to
do more to give the NHS more input into the whole NICE processes.
This was a matter that I discussed with NICE at our last meeting
and they have said that they have taken that on board. That is
one of the reasons why on the appraisal committee for a particular
appraisal there will be two health authority representatives to
give a considered NHS input. Equally, I want to encourage the
NHS themselves to be much more proactive in suggesting guidelines
or appraisals for NICE to consider. They have a lot of experience
in the front line about particular treatments or drugs where there
may be uncertainty or controversy where definitive advice from
NICE would be welcome. At the moment we have not been too successful
in getting the NHS to come forward with many ideas. I would regard
that as a key challenge both for us as a department and for NICE
to get much more NHS input. When I say NHS of course I mean the
NHS organisation but also individual clinicians as well.
501. What about the circumstances in which NICE
looks at two drugs, A and B, and they recommend drug A? What do
you do with the clinician that continues to want to prescribe
drug B and tells their patients that that is the best thing?
(Lord Hunt of Kings Heath) The position on that is
that of course ultimately individual clinicians must make their
own individual decisions but, through the clinical governance
arrangements that are in place in every organisation, they would
of course need to explain and justify why they have done that.
Obviously my expectation is that NICE guidance will be credible,
that the profession will see it as credible, and will see the
merit in following the advice that they give.
502. Will there be a way for them to continue
the debate with NICE if they wanted to?
(Lord Hunt of Kings Heath) Yes, and again, just as
we have talked about the importance of patient groups and the
NHS being involved in discussions with NICE and the other organisations,
the professions themselves have a vital role to play. It is interesting
that in relation to the clinical guidelines the nursing and medical
Royal colleges have a very important role to play in collaboration
with NICE on those guidelines, so yes, very much so.
503. You focused there on clinicians. When we
had the health authority witnesses coming to the Committee, there
was a real concern that NICE's estimations of cost effectiveness
are not the same as their own and do not match their budgetary
decisions that they are having to make. What is your view on that?
(Lord Hunt of Kings Heath) There are two things there.
First of all, why are we here? We have postcode prescribing which
many of us find utterly unacceptable. Whilst I am very committed
to giving as much freedom as we can to the NHS locally, the fact
is that it is those very NHS organisations who presided over a
very inconsistent practice, so I am afraid I am not that sympathetic
to that complaint coming from the NHS. Nor am I sympathetic to
the suggestion that somehow or other NICE guidance distorts NHS
priorities. I tell you that getting NICE guidance implemented
in the NHS is one of the Minister's key priorities because we
want to end postcode prescribing; we want to see much greater
consistency. The fact is that alongside national service frameworks
we are focusing on what we regard as the key clinical priority
areas, so I am not at all sympathetic of that viewpoint.
504. Two questions arise out of that. If that
is the case why, when NICE first came in was there not guidance
issued which was issued recently, the directive saying that all
NICE guidance should be mandatory now? Also, as with beta interferon,
the guidance came out saying that it was effective for some patients
but in cost effective terms it was not persuasive. Does that not
of necessity mean that NICE is looking at some treatments that
might be at the margins of cost effectiveness which clearly, when
you take it down to a health authority level, might mean that
health authorities' balance of cost effectiveness would mean that
it would be different from the national priorities?
(Lord Hunt of Kings Heath) There are two points to
be made about that. The first is that in terms of the resources
that are available to the NHS we are in a position where the NHS,
as you know, is receiving record increases in its resources.
505. You mean there are not pressures there
all the time?
(Lord Hunt of Kings Heath) We all understand the pressures
and of course we are now going through the annual agonies of the
SAFF round where everyone shouts to the hilltops about their problems
and then coming to agreement. You well know that process which
takes place every year the NHS has ever existed and we are in
that at the moment. The fact is, however, that in the additional
resources that the NHS is receiving they have enough money to
be able to fund the impact of NICE guidance as well as the priorities
that we have established. In terms of the NHS, of course I understand
the cost pressures, but I do not believe that anything that we
have done detracts from the affordability of the NICE decisions
at local level. Of course, if you want to end postcode prescribing
you are constraining the ability of people at local level. You
are saying, "In this area we are insisting that you fund
it", but I think that is right because that is the only way
in the end we will end postcode prescribing.
506. Would you just answer my other question
about why not mandatory from the beginning?
(Lord Hunt of Kings Heath) Why we did not issue directions
to the NHS to fund guidance?
(Lord Hunt of Kings Heath) We obviously expected that
the NHS would implement NICE guidance. By and large I think they
have, although we have heard concerns from various people that
they have not. My own viewit is the Government's viewis
that the whole integrity of the NICE process depends on their
guidance being implemented. We all know the history of the NHS
which is that there were good reports being issued which were
not implemented. There was no point in our establishing NICE unless
we could be assured that what it advised the NHS to do actually
happened. To make doubly sure we issued these directions early
508. We know the Government is putting more
money into the NHS but I would suspect that every health authority
would disagree with what you say, that they have been given enough
money to do their priorities and to implement NICE guidelines.
The trusts that have talked to us have given us stark examples
of either doing something recommended by NICE or having four extra
casualty nurses. I would think very strongly that every trust
and health authority would disagree with that statement.
(Lord Hunt of Kings Heath) I do not think it should
be an either/or position, should it, because the money that we
are putting into the Health Servicewhat are we talking
about: 6.25 per cent extra reel-terms growth in the current financial
yearis there to fund the impact of NICE guidance, yes,
but also to develop the service. Of course every individual organisation
is going to have to make difficult choices about where they spend
the additional money but I do not accept that by making it a requirement
that NICE judgements are financed somehow or other you are debilitating
the public in a particular vicinity because you are having to
curtail services. I do not accept that. I believe that the implementation
of NICE guidance is to the benefit of the public and I believe
that overall the financial settlement is sufficient to allow the
NHS to develop its capacity. Of course all of us who have been
involved in the Health Service will know that you will never ever
get enough money to do everything that you want to do. This does
not detract from the fact that at local level people have to make
difficult decisions. Of course they have to make difficult decisions.
But you come back to the original principle: why are we here?
We are here because we want greater consistency; we want to make
sure that the most robust evidence that is available translates
itself into local decisions. That is why we set up NICE and that
is why we are in effect instructing the Health Service to finance
509. This is why I think NICE is fairly badly
flawed right from the beginning, because it focuses the desire
for money on the things that it examines and the things that it
does not examine, perhaps, get pushed down the list, and these
could be of equal importance or greater importance.
(Lord Hunt of Kings Heath) You have to put it in perspective.
We reckon the gross costs over the last 12 months
510. I am not trying to say there will be enough
money for everything.
(Lord Hunt of Kings Heath) The gross costs of the
drugs recommended by NICE over the last 12 months is roughly round
£300 million. That is a substantial amount of money, but
compared to the overall money spent on the NHS, I would suggest,
that is a fairly small element. I would not accept that the impact
of the NHS having to fund NICE guidance is so great that it is
having a distorting effect on local priorities. It is one of the
cost pressures that they have to face and it is something that
we take into account when we allocate money to the National Health
Service and negotiate with the Treasury how much money they should
511. Do you have contingency plans if it does
happen, if that expense is too great?
(Lord Hunt of Kings Heath) I hope that that will not
arise. Obviously it is not a risk as of yet. I suppose in a hypothetical
way you reach a situation where a particular appraisal was likely
to lead to huge expenditure in the NHS, which it was felt could
not be afforded in any one financial year. The government would
obviously have the option of issuing modified directions to the
NHS which might say that has to be phased in. If it were to do
that my colleague John Denham, the Minister responsible for NICE
when it was established, has already said that if that were to
happen then the Government would make a statement round it. I
hope that does not arise.
512. I have a question, very briefly, on this
question of costs. I can understand what the Minister is getting
at. Did you notice about three weeks ago in our House one of your
ministerial colleagues published a report of health authority
by health authority on, in most cases, the drugs deficit which,
I think, if you tot it upthere were a few that had not
gone into deficitthere was an overspend of about £300
million this year. How is that going to be recouped? Will services
be cut to recoup it or will the government make additional resources
available to help them get over these deficits?
(Lord Hunt of Kings Heath) No, the Health Service
will have to find the money from its own resources, and that is
quite proper, particularly out of the amount of money we are putting
(Lord Hunt of Kings Heath) It is a cost pressure that
the NHS will have to face up to, like other pressures as well.
514. I presume fairly soon because the financial
year ends in three weeks!
(Lord Hunt of Kings Heath) Let me make two points,
first of all we are talking about £5 billion spent on drugs
in the NHS.
(Mr McKeon) It was rather more than that, £7
515. £300 million is quite a lot if it
has to be found by the end of the financial year, I was just asking
how the government is going to find the money to meet this deficit?
(Lord Hunt of Kings Heath) We would expect the NHS
to meet any additional cost for drugs from its existing resources.
516. How, by cutting the service?
(Lord Hunt of Kings Heath) In the normal business
of the NHS, juggling competing pressures they will have to find
ways in which to do so.
517. Does that mean cutting services, because
they have three weeks to the end of the financial year?
(Lord Hunt of Kings Heath) The issue of cutting servicesyou
are almost suggesting that the increase in drug costs is per
se bad and that has a negative impact on services.
518. I have not said anything at all. I asked
how the money is going to be found?
(Lord Hunt of Kings Heath) I do not take that view.
That is why we have prescribing advisers, they are very helpful
in doing that. Ultimately if drugs are effective then we should
not see a rise in the drug bill as necessarily per se a
bad thing. All I am saying to you is that the NHS has to deal
with cost pressures all of the time. Events are always occurring,
you can have problems with the increase in the number of people
coming from emergency admissions, all of those are pressures,
and the NHS has to handle that.
Mr Burns: Can I deduct from that answer, Minister,
you do not know how this money is going to be found?
Siobhain McDonagh: How do you know what every
health authority is going to do on an individual basis?
519. I am waiting for the minister to answer.
(Lord Hunt of Kings Heath) I just told you, with the
greatest respect, Mr Burns, that I would expect every local NHS
organisation to contain its cost pressures.