2 February, 2002
Katherine Burke London
The health service is too cash strapped to follow national guidelines on clinical excellence, health authorities told MPs last week.
Their comments came in the same week that the institute dismissed an appeal by charities and drug companies against its final appraisal determination on interferon beta and glatiramer acetate. The National Institute for Clinical Excellence (NICE) ruled last year that the use of these drugs for patients with multiple sclerosis was not cost effective but recommended that the Department of Health, the National Assembly for Wales, and the drug manufacturers should consider ways of making the drugs available in a cost effective manner.
This resulted in the government announcing in November that it would consider funding a "risk sharing" scheme, in which the drugs would be funded only if treatment trials in individual patients showed they were effective (10 November, p 1087).
A House of Commons inquiry heard last week how health authorities could barely afford to implement the government’s top 20 health priorities, never mind the NICE guidelines.
According to Croydon Health Authority, implementing the government’s top 20 recommendations would cost the authority £70m ($99m ; €114m)—at least 10 times the available budget.
Lambeth, Southwark and Lewisham Health Authority has calculated that NICE guidance would cost £15m to implement in 2002-3, depriving patients of other equally effective interventions, such as new antirheumatic drugs. Last year the authority had only half the money it needed for new drugs—£2m above inflation versus the £4.6m required.
Dr Deirdre Cunningham, Lambeth’s director of public health and health systems, told the House of Commons health committee inquiry that NICE guidance had had to take a back seat to ensure the authority met more important national targets.
"We are struggling to meet the government’s emergency care and other top priorities. We thought it was a sacking offence not to meet them," said Dr Cunningham.
But now that health authorities were also obliged to meet the NICE requirements in cancer treatment, Dr Cunningham feared that other priorities such as emergency care and waiting lists would suffer.
"The government has given an uplift but has also increased the targets. If we have to fund [interventions approved by NICE] we want to be very involved in their selection," she told MPs.
Dr Tim Crayford, deputy director of public health in Croydon, queried NICE's decision to recommend investment in implantable cardiac defibrillators—which cost £30 000 per patient. His health authority calculated that with the money it had spent on four such devices, it could fund four extra accident and emergency nurses instead.
"The nurses we put in accident and emergency very nicely stack up against the defibrillators," said Dr Crayford. "We don’t need a lot more help to say ‘yes’ to interventions; we need help to say ‘no’—a filtering out process."
Health authorities were sceptical about NICE’s declared independence from drug companies and government, the inquiry heard. The witnesses agreed that NICE should publish, in the guidance itself, any conflicts of interest among its committee members and advisers.
"Some parties advising NICE have relations with the pharmaceutical industry," said Helen Marlow, pharmaceutical adviser to Croydon Health Authority. "There is a whole move towards integrity in the medical journals and the NHS, and I think it would improve the competence of NICE if that information was shared."
Also speaking at the hearing, representatives from the Association of the British Pharmaceutical Industry denied claims that members had tried to influence NICE's decisions and that drug companies had withheld important evidence from the institute.
"We would absolutely refute it," said Dr John Patterson, the association’s president elect and the vice president (product strategy and licensing) at AstraZeneca.
The association queried NICE’s role in assessing new drugs—pointing out that the Medicines Control Agency already did this job. The association has been in talks with the Department of Health for at least six months over the way in which the institute’s workload is allocated. A NICE consultation document is expected within weeks on this subject.
Witnesses from the Campaign for Effective
and Rational Treatment (CERT) and the Association of the British Pharmaceutical
Industry claimed that many women with aggressive breast cancer had died
prematurely because NICE’s appraisal of a new drug was already six months
late. According to the campaign, which is funded by drug companies, about
5000 women a year were suitable candidates for treatment with the drug
trastuzumab (Herceptin), but only 200 had received the drug because health
authorities were awaiting NICE guidance.