The current system for assessing treatments for the NHS is too slow and cumbersome, says a Commons Committee. The Committee says NICE (National Institute for Health and Clinical Excellence) should adopt a system similar to Scotland’s, where a more thorough review can be carried out later.
The Commons Committee only advises. It is for government and parliament to decide whether to implement the Committee’s advice.
NICE’s job is to decide which treatments and drugs the NHS should provide. It considers this by assessing the cost and effectiveness of each treatment/drug(s). NICE directives cover England, Northern Ireland and Wales. Scotland’s Scottish Medicines Consortium makes such directives for Scotland.
The Committee prefers the Scottish Medicines Consortium’s system to NICE’s. It says the Scottish Medicines Consortium makes decisions much faster than NICE, because their appraisals are a good deal simpler. A typical Scottish Medicines Consortium’s appraisal can take a couple of months, compared to 9-12 months in NICE’s case.
The Committee also advises that NICE be made to appraise all new treatments, not mainly the expensive ones. NICE’s tendency to appraise mainly expensive hospital treatments regularly resulted in effective, cheaper treatments which GPs can deal with being ignored.
The Committee advised that NICE ignore the £30,000 threshold for new treatments. This threshold is not based on science, the Committee said.
The committee identified several problems with the evaluation process, including:
— Topic selection. Only a few selected medical technologies are chosen as suitable for assessment as technology appraisals. There is also far too little emphasis on disinvestment. Here the Committee found NICE’s responses to their questions disingenuous. While few older treatments may do no good at all, many will not be cost-effective.
— The wider benefits of treatment to society, for example to carers, are not included in NICE’s economic evaluations.
— NICE often does not have all the information it needs to make a full assessment. It does not have access to all the information the Medicines and Healthcare products Regulatory Agency (MHRA) uses and clinical trials are usually designed without NICE’s work on cost-effectiveness in mind.
— Experts are not sufficiently well used.
— Publication of guidance is slow; licensed medicines are often not prescribed while PCTs and clinicians wait for NICE to make a decision.
The Committee made some recommendations to address these problems. It says there is a need for a system whereby all medicines are assessed when they are launched. A shorter, less in-depth evaluation should be made between the time of licensing authorization and marketing, so that doctors can prescribe useful and cost-effective drugs the moment they are launched. A lower cost-per-quality adjusted life year (QALY) threshold should be employed during this early assessment to ensure that only the products that are most cost- and clinically effective are available at once. Subsequently, there should be a full appraisal; the threshold could then be increased if necessary.
NICE needs to have access to the same material used by the licensing body, clinical trials should be registered and there should be closer working between NICE and the pharmaceutical industry. This will be particularly important for the effective assessment of drugs in time for launch.
The Committee recommends that more be done to encourage disinvestment. No evaluation of older, possibly cost ineffective therapies has taken place to date; two are currently underway. The previous Committee made the same recommendation. The present Committee says it is not acceptable that NICE continues to ignore this recommendation.
The Committee wrote “Our last report on NICE also recommended that the legislation be changed to accommodate the need to ensure that assessments of products take account of the wider benefits to society; we make the same recommendation here.”
In order to improve the realization of NICE guidance, the Committee recommends:
— More help be given to for PCTs to implement guidance.
— There should be a better assessment of the level of uptake.
— PCTs should play a larger role in the development of guidance.
— There should be better use of experts in the development of guidance.
— NICE should change its terminology use to clarify to patients what they can and cannot expect by right from their local NHS organization.
The Committee also recommends that elements of clinical guidelines be made compulsory. A suitable example would be risk assessment for all patients at risk of developing venous thromboembolism.
The Committee concluded that NICE carries out a vital role in difficult circumstances. “The development of more and more health technologies and procedures, alongside rising patient expectations and the ageing population, is going to make it even more difficult in the future. Healthcare budgets in England, as in other countries, are limited. Patients cannot expect to receive every possible treatment. Demand outstrips resources and priorities have to be determined. In other words rationing is essential, and NICE has a key role to play. In the past NICE has changed in response to new challenges, and we are sure it can do so again. Given the difficult environment, NICE requires the backing of the Government. Ministers must support NICE, not seek to undermine it. NICE must not be left to fight a lone battle to support cost- and clinical effectiveness in the NHS.”
— Click here to see the Health Committee’s Report Online
Written by – Christian Nordqvist