Review of NICE drugs, treatments and devices

In January 2020 the Committee for Health & Social Care presented its policy letter to the States. We proposed that all NICE drugs, treatments and devices with technology appraisals be phased in over 4 years, with an interim review. Here is the speech I made to open the debate.

Sir, 

On behalf of HSC I am delighted to present our findings and recommendations following a review of drugs, treatments and devices. The Committee honoured the direction of the States in publishing its policy letter in time to meet the 2020 Budget, albeit that we are only now debating it. A lot of work was done in a relatively short space of time to get us to where we are today.

Firstly I should like to say that the Committee is very grateful to Solutions for Public Health for an excellent piece of work. Their knowledge and skills were evident at all stages of the process and have enabled us to present proposals based on detailed, impartial and expert evidence. Consultants have had a bad press and in some cases justifiably so – taking our watch, telling us the time and going away with handsome reward, but not in this case. We should also like to thank all those that contributed to the process, fellow members, those with a specific interest, as well as members of the general public. Their views have all been considered in the development of this policy.

Before highlighting the key proposals I think it really is important to say that the current policy which has, to a large extent, been in existence for the last 17 years, has been effective in controlling the rate of increase in health costs over a period of considerable budgetary restraint. Officers have done an excellent job working within this policy and, if they had not done so, health overspends would probably have been much higher and the balance on the Health Service Fund considerably lower. We must not forget that and it is something I will come back to at the end.

Understandably, those arguing for extending the drugs and treatments available do so in terms of fairness. That it is not fair that people in England get access to drugs not available here. However, that is not the only factor that needs to be taken into consideration. 

As I said during the debate on Deputy Roffey’s requete, Our current policy was designed before the Partnerhsip of Purpose was developed and approved by this Assembly and the Committee as part of that policy letter stated the need to ensure future policy aligns with it and in particular the key aims of fairness, prevention, user-centred care, proportionate governance, a focus on quality and empowered providers and integrated teams. These aims were specifically stated in the terms of reference of the proposed review.

And it is as a result of that review that we believe the current policy has created disparity between the drugs available to patients in England and those available to patients in the Bailiwick, such that the gap is now too large to be acceptable and a change in policy is necessary if this is not to worsen. Indeed, since the review was undertaken an additional 51 TAs have been approved.

A number of members spoke in the last debate about the need for people to have access to what they stated were life-saving drugs. However, it is important to note that many of the drugs and treatments approved by NICE that would become available to Guernsey and Alderney residents are life extending rather than curative treatments. As such, they can’t be considered life-saving although some of the newer treatments do have the effect of reducing often uncomfortable side effects and enable patients to maintain a greater quality of life during treatment than some of the existing treatment pathways and are expected to be one of the major benefits of adopting NICE TAs.

In summary we propose that the States should, in principle, move towards funding all drugs, treatments and devices with a  TA from NICE, including those approved for funding from the Cancer Drug Fund and hat treatments should be phased in based on a universally accepted method of differentiating drugs, known as the incremental cost effectiveness ratio. 

We are also proposing that the next Committee report back to the States after 2 years and before full implementation for 2 key reasons, firstly, additional staff, resources and infrastructure changes will all be required before NICE TAs with an ICER of over £40k can be introduced. Secondly,  as NHS Social Judgements states, advisory bodies need to make a stronger case for interventions  above an ICER of over £30k.

It is important to make clear that the complexity of the work has meant that it has been necessary to make a number of assumptions about the anticipated costs of adopting NICE TAs. It is therefore essential that members take the figures in this policy letter as best available estimates at this time. In the case of backlog costs in particular it is assumed there is no decrease in costs over time. However, it is more likely that regrettably some of those patients receiving newly introduced TAs will pass away each year and will not require treatment on a long term basis. However, determining mortality rates would be a very difficult exercise to undertake and certainly not possible in this timeframe.

A non-statutory approach is being proposed to ensure best value for money. I need to make it very clear here that this is not because we don’t acknowledge the expertise of NICE, we do and follow its published guidance on most areas within health and care in fact, but rather because it will allow for some of the bias in the NICE TA process to be neutralised. I think I should also advise that through ESS a lot of work is done to maximise the use of generic over branded drugs. 

There are additional costs if we are to extend the drugs and treatments in the way envisaged beyond the cost of the treatments themselves. It will also require additional cost and resources through communication, developing new pathways, new internal policies, audit of new TAs, new staff and new software. A lot of thought and planning will be required to ensure things go smoothly, as well as to ensure the public is aware of the new policies and that we can provide greater transparency over the processes we bring in.

Sir, we have already had a debate on the pressures on finances. We have debated the merits of spending money on one thing or another.

And I said at the start how the current policy had served the States well during considerable budgetary restraint. But the question we must ask ourselves now is, has the time come where it is not serving its people well.

And that leads me to P&R’s letter comment. 

 In it they say that the States are being asked to make a value judgement regarding the point to which the investment of resources in improving the quality of life and wellbeing of potentially small groups of individuals represents an effective use of resources in achieving the vision of becoming the “happiest and healthiest place in the world” for the community as a whole. 

Well let’s dissect that statement for a minute. Firstly, members need to understand that these are the decisions HSC has to make all the time.

BUT it is not just a simple matter of looking at the number of individuals involved. After all, we spend upwards of a quarter of a million pounds each on liver, kidney and heart transplants which benefit just a handful of people each year. Indeed, we have had a particularly high number last year that impacted on our off-island budget.

BUT these benefit a very small numbers of people. However, we do so, because of the proven clinical and cost effectiveness. It is for the same reason we are saying that NICE TAs with an ICER up to £40k should be funded, but that we should undertake a review after 2 years, particularly to determine whether it is justifiable bringing in those with higher ICERs. And it should be noted here that we are not necessarily talking about the cost of those drugs. We are not saying drugs costing over £40,000, but their Incremental Cost Effectiveness Ratio – the amount of money needed to be spent to achieve 1 additional quality adjusted life year with one medicine compared to another.

We make it very clear that funding new drugs and treatments should not be at the expense of other investments in the health service which support the long-term transformation of health and care. As I said in the last debate the current budget levels are unrealistic even before considering more drugs and treatments. Where would the funding come from? 

The easiest things to do would be to cut the off-island budget for tertiary care not provided here such as radiotherapy, complex surgery and other cases thus penalising one group for the benefit of the other. I can’t see that as being politically acceptable. Other areas that support prevention and early intervention are often the first to be cut when budgets are tight, but that is cutting off your nose to spite your face and will only lead to greater cost further down the line. Indeed, focusing on prevention and early intervention is the means of preventing people from needing many of the new drugs and treatments in the first place. Screening may give short term benefits but it is through other public health measures, such as through preventing obesity, smoking and excess alcohol consumption where we could really cut the drug bill, but we are only likely to see the benefit of that in the medium to long term.

The solution proposed, which has been agreed by both P&R and ESS is that we seek funding from general revenue until legislative changes are made that mean it can come from the Guernsey Health Reserve for the first 2 years which would mean up to £5.6m in year 1 and £8.3m in year 2.

This is a considerable sum of money, although based on a worst case scenario as I have said. However, I find it interesting that this is the first letter of comment I recall coming from P&R that compares the cost to the percentage of particular taxes. I have no problem with that. We should probably do it more often. However, I don’t recall any such comparison being made when we were asked to support a supposedly temporary overdraft facility for Aurigny of over £25m in the last budget, extra funding for digital transformation, or the £8m requested for public sector reform, none of which benefit the people of Guernsey and Alderney immediately or directly.

So much of what government does, whilst incredibly important, does not benefit our people directly. If this policy letter is approved we estimate over 3k people’s lives may be made better. That’s the equivalent of 2 colleges of 1,500 students each. Is that not enough people to care about?

I think it is also worth bearing in mind paragraph 3.5.4 of the main report where it states;

‘The long term position of late or never adoption of newer, effective interventions won’t only affect patients but may also have an indeirect, adverse effect on the ability of clinical staff to be able to maintain their professional standards or for younger doctors to take full clinical responsibility for prescribing older treatments with which they may be less experienced and, in the long term, attract and recruit clinical staff.

Ultimately, and probably most importantly, given the last debate, supporting these proposals today will reduce inequality by making available drugs that are currently only available to those who can pay.

Our proposals are expected to help thousands of people, not a handful. Thousands who may live longer, may live in less pain or be able to live independently and productively for longer.

If that isn’t considered to help us become one of the happiest and healthiest places in the world I don’t know what does.

Sir, I ask members to support this policy letter.



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