The National Institute for Health and Clinical Excellence (NICE) has an important role in the introduction and adoption of new treatment and therapies within the NHS. NICE offers guidance and assessments on a range of treatments and pathways, but only its technology appraisals are mandatory in their adoption by PCTs.
Technology appraisals are recommendations on the use of new and existing medicines and treatments within the NHS in England and Wales, for instance:
- medical devices (for example, hearing aids or inhalers)
- diagnostic techniques (tests used to identify diseases)
- surgical procedures (for example, repairing hernias)
- health promotion activities (for example, ways of helping people with diabetes manage their condition).
This is an important distinction since NICE provides a whole range of services and there is a misconception that all are mandatory. What this means in practice is that once NICE publishes a technology appraisal, the commissioners are obliged to proceed to implementation. This is a patient right, and it is enshrined within the NHS constitution.
What is now being proposed is that NICE will be responsible for creating a compliance regime through its technology appraisals system. This will mean that a scorecard will be published, it is hoped by the end of 2012, which will assess each CCG on its compliance and implementation.
Clearly there will be some preparatory work required and so a NICE implementation collaborative is being established to help providers implement new guidance.
This collaborative will bring together representatives from the NHS Commissioning Board, the Chief Pharmaceutical Officer, main industry bodies including pharmaceutical companies, the NHS Clinical Commissioners (the coalition comprising the NAPC and the NHS Alliance), the NHS Confederation and the Royal Medical Colleges.
What will this mean for CCGs? At present there is no system for ensuring that technology appraisals are widely offered. Often the implementation of new therapies does not reach the right level and falls foul of the requirements around the contracting process between commissioner and provider. A ‘failed’ implementation is often one of the ‘also rans’, where implementation is deferred or delivered inconsistently.
The introduction of the new Health Act offers the opportunity to make the process of implementation more consistent, and it is our responsibility to ensure we do our utmost to make this work. It will be helpful to reflect on how the reforms change the present ways of working and also what the potential tensions are, to attempt to manage these better.
In the new world, the local NHS will become an additional part of the offering to patients. What this means in practice is that the services patients get in their locality will be determined by the needs of that population. There will probably be variations in delivery of services from area to area, but this is no bad thing if the services on offer reflect local needs.
This of course, does not mean we will not have a National Health Service. The NHS will continue to develop and indeed national technology appraisals are part of what the NHS delivers. As mentioned before, these technology appraisals are enshrined within the NHS constitution as what both patient and population can expect to receive. If these are not delivered, the patient has a right to legal redress.
There is some tension between a local NHS and a national NHS and we need to be aware of this. The technology appraisals need to reflect what the National Health Service offers, and should be relatively few in number. If there is a phalanx of these we will lose the sensitivity and granularity that local delivery of care is supposed to deliver.
There is also some tension between the rights of a patient to treatment and the effect of these rights on the right of a population for comprehensive healthcare. The NHS is a universal state-funded system and inevitably is financially limited. Thus we need to ensure that the rights of the individual do not overwhelm those of the population.
Both these tensions should be managed carefully and we need to ensure we are open and transparent about our aims, as well the processes we are using to reach them. We have some way to go here as our populations are not hearing these messages from the politicians.
Implementation will entail starting a dialogue with secondary care and it is important to set some parameters around this.
Firstly, there is a danger that any new technology appraisal will be considered an addition to the offering the hospital trust already offers, but they are not meant to be new sources of income. The days of increasing activity as an antidote to more efficient contracting and pricing are long gone. There was a time when the acute sector seemed to increase activity in proportion to diminutions in tariff, to maintain or in some cases increase income flows.
This will no longer work. The new world of austerity is one of cooperation and transparency, where the care of a patient is delivered within budget. If acute care costs more, then primary care providers will have to accept that their funding will fall commensurately.
The advice is, then, that any new activity is not to be considered extra, but instead substitutes something that may no longer be a priority. We are very good at starting new schemes but less good at shutting services down. The challenge will be to ensure we incorporate the new technology appraisals into our existing pathways and guidelines to ensure we are managing our populations consistently.
It is important to ensure we do not get overwhelmed by the amount of guidance on implementation. Some commissioners advocate that NICE also delis detailed guidance on implementation, and whilst this may be helpful in acting as a reference it must never be implemented prescriptively as if it is we will lose the local sensitivity which is at the heart of the reforms.
There are other important players to be engaged. One ‘key player’ is the patient population, and this is a good opportunity to reach out to them.
The other is the pharmaceutical industry, with whom we need to recalibrate our relationship. The behaviours of the past, where we spent most of our efforts trying to ensure we neutralised any advertising of new products, may not be sustainable. The pharmaceutical industry has a role to play and needs to make a turn on investment on its products. It also needs to understand that its offering needs to be more than a ‘novel molecule’. Adherence of patients to their medication and treatment is at least as important, so we need to start to develop ways of working cooperatively.
Some GPs are concerned about possible conflicts of interests, but these can be managed. As long as any potential benefits flow directly into patient services, and the processes we use are transparent and fair where procurement is part of the offering, we should not worry. The ABPI have also recently altered their code of conduct making engagement easier when a pharmaceutical company and a CCG work together on a whole pathway.
In conclusion, we should look at this new initiative as an opportunity to engage with our patients, local practices , acute trusts and the pharmcetuical industry.
We must remember what we are trying to manage, why it is important and that the goal is not necessarily making financial cuts but treating the maximum numbers of people in the most efficient way possible. It will take the talents of all players to make this more than an aspiration.
Dr Charles Alessi is a GP in Kingston and chair of the NAPC
NICE. Technology appraisals. 2012. http://www.nice.org.uk/guidance/index.jsp?action=byType&type=6