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Briefing Document Advocating the Establishment of PRICE:
for the Public Rationing and Implementation of Clinical
Excellence. [email protected]
Recently the Health Committee conducted a review into NICE concluding that:
Demand for NHS services will always exceed the ability to meet it. Not every treatment can
be provided to every person. NICE has a vital role to play in the rationing arrangements and,
working with Government, should make clear to the public how and why such decisions are
made. (HC, 2007 p. 69)
Now the NHSs being tasked to reduce costs by as much as 20bn by 2014 (HSJ, 2009) I feel that
technical and allocative efficiency must be dealt with head on, in a very transparent manner.
Since its conception NICE has moved from assessing new technology, to focusing more on value for
money and half of its clinical guidelines are now concerned with long-term chronic conditions. (NICE,
2008) It has thus far operated during an unprecedented period of sustained growth in the overall
NHS budget, 7.3% annually since 2000 and has had a degree of success in this area with several
studies showing its guidelines lead to more cost-effective use of medical devices as well as with
certain drugs for cancer, obesity, and Alzheimer disease. (Pearson & Rawlins, 2005) However this
period has come to an end and the Health Committee believe NICE must now change again:
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. (HC, 2007 p. 95)
I believe the report is right in many respects. NICE has indeed overcome many challenges; many
countries look to it as leading the way, and even its critics highlighting the value of its work. (Bryan
et al., 2007; HC, 2007) However with respect to public health there are inherent problems with the
present situation. As NICE (2008 p.9) indicate, statutory instruments and directions do not allow
(them) to take budgetary impact or affordability into account when advising on cost effectiveness.
During the inquiry, doubt was cast on whether NICE alone should continue to determine the level of
the threshold at which technologies are approved. NICE (2008, p.10) also consider the current
situation unworkable within their remit, recommending that:
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A separate body, with representation from NICE, the Department, PCTs and others should set
the level, or range, to be used. NICE's threshold should be closely linked to that used by PCTs.
The threshold should also relate to the size of the NHS budget.
It is my belief that PRICE should be that body.
The current problem.
I feel there are 4 main issues that need to be addressed:
1. Opportunity CostThis pertains to the argument that with a limited budget the decision to fund one course of
treatment is ultimately made at the cost of not funding something else. (Williams, 2005) Birch
&Gafini (2004) provide critique of economic basis of NICE decisions concluding that since theanalytical basis of the NICE guidelines pay no attention to this issue although theymay be useful in
dealing with administrative process but are ultimately unlikely to be well-suited with the effective
use of NHS resources. Also, by approving technologies of marginalcost effectiveness, NICE is
inflating NHS spending with smallhealth gains for the population.Maynard (2008 p.907).
2. Underuse, OveruseMisuse and VariationThe Institute of Medicine (n.d., 1999), identify three main areas where evidence can identify
practices where there is potential to improving care and/or reduce costs.
a. PracticeOveruseE.g. A retrospective study (Bernstein et al., 1993 p.8) showed by UK standards one
half of coronary angiograms were performed for equivocal or inappropriate
reasons.
b. PracticeUnderuseE.g. A US study (RAND, 2004) has shown that Americans receive only about half the
care they need. In the UK, the Government has recognised similar deficits in the
delivery of appropriate primary care.
c. PracticeMisuseE.g. Safety is a big issue in Healthcare as Davies et al., (2004) show of the top 20 risk
factors that account for nearly three quarters of all deaths annually, adverse in-
hospital events come in at number 11 above air pollution, alcohol and drugs,
violence and road traffic injury.
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There is also considerable variation in activity rates in healthcare. For example with respect
consultant surgeons in the English NHS, interquartile variation shows that the top 25% of
consultants have activity rates 60 to 85% higher than the bottom 25%. (Bloor et al., 2004 p.76) As
the Health Committee (2007, p.96) concluded; many treatments currently used are not cost
effective as many studies attest. NICE should adopt a similar standard of cost effectiveness in
assessing such treatments as it uses in its technology appraisals. The organisation must now give
more emphasis to disinvestment.
3. Insufficient Legislation and ResearchThe HC report (2007, p.12) also highlights that NICEs public health recommendations are currently
advisory and not mandatory,although in 2003 it became a legal requirement that funding for all
positive advice arising from technology appraisals should be made available within three months ofpublication in order to improve consistency in patients access to treatment. This is has lead the
somewhat absurd situation where new NICE guidance is mandatory, andPCT are obliged to fund its
decisions; yet without any budget restraint this can lead inflationandbias when setting priorities.As
a result of this there can be pressure on PCTs to fund new technologies with arguably marginal
benefit at the expense of increasing funding to other cost effective areas. (Maynard, 2005(a)) To
date this issue has largely been avoided by claiming there to be plenty of money to go around but
now funding has been cut, or at the very least is not expected to increase in the immediate future, I
believe the issue can no longer be avoided. In addition there is a lack of research into the level ofimplementation of current guidelines (HC, 2007) and limitations as to the evidence base for
managerial implementation. (Rousseau, 2005;Rousseau &Mccarthy 2007; Walshe&Rundalls 2001) In
other words, even where we do know what we should be doing we dont know the best way to
achieve it.
4. Political and Public PressureHealthcare is a very politically emotive subject, an example the Health committee report (2007)
chose to pick up on was when the Rt. Hon. Patricia Hewitt MP publicly voiced concerns over the
refusal of a PCT to prescribe trastuzumab (Herceptin, a then unlicensed indication un-assessed by
NICE), to a patient with breast cancer. Making it almost impossible for NICE not to approve the drug,
once licensed, regardless of cost. (HC, 2007 p.9) When questioned by the committee the then
Minister of State, the Rt. Hon Dawn Primarolo MP, stated I would absolutely stress that it is not the
role for ministers to contradict, override or directly seek to influence a process where NICE are
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already engaged inconsideration.(HC, 2007, p.25) adding that NICEs final guidance will be final
(HC, 2007 p.25). The HC note that it is not the role for Ministers to directly or indirectly seek to
influence the NICE decision-making process.(2007, p.25)
Public opinion voiced by the media plays an imported role here as one media consultant states
"patients are a powerful force and can highlight the clinical, societal and quality of life benefits of a
treatment far more passionately than any press release ever could."(Spinks as cited in Ferner&
McDowell, 2006 p.1269) A Cochrane Study (Grilli et al., (2002 p.1) into this subject concluded mass
media information on health-related issues may induce changes in health services utilisation, both
through planned campaigns and unplanned coverage. Recommending further research be
conducted on whether and how media messages have a different impact on members of the public
and health professionals; and more information be collected on whether mass media coverage
brings about appropriate use of services in those patients who will benefit most. In addition the
Pharmaceutical Industry plays a big role; as Ferner& McDowell (2006) highlight, a study found 76%
of patient groups received support from drug companies in the EU, (though how much was unclear),
and groups campaigning for NICE to approve specific drugs have often declared corporate relations.
Where PRICE would operate
In its founding I envisage PRICE be mandated to address the legal issues discussed above. Like with
the approval of new technologies its guidance should be a statutory requirement. The bulk of its
work would be to firstly assess and secondly enforce rationing thereby addressing opportunity cost
as well as overuse, underuse misuse and variation in resource utilisation. It would work closely with
the DH, the NHS, Parliament, the Public and Press as well as independent bodies such as NICE and
Monitor. In addition to this it should help to signal what new products are desired by the NHS;
helping to steer research as consequence.
Addressing Opportunity Cost
As Smith highlights (HC, 2007 p.61), this is a delicate balancing act; if we adopts too high a threshold
technologies might be implemented that drive out more cost-effective treatments. If we adopt to
low a threshold it may limit development and adoption of newer more cost-effective treatments.
Bryan et al. (2007 p.189) have produced an interesting paper following interviews with many people
at NICE finding The line put forward by many interviewees on the threshold subject was that there
was not a precise value to the threshold but that when the ICER exceeded 30 000 per QALY this
began to signal that the technology was unlikely to be cost-effective. This is backed up by Devlin
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&Parkin (2004) who find support for a threshold based on a range determined by calculations of
probability as opposed a single value;their analysis suggesting it is higher than NICE identify
publically.
PRICE would ultimately have to set threshold ranges per QALY related to NHS budgets, but decisions
should not be, (or seem to be), based purely on the maths. The case of Oregon of shows how
mathematical based rationing was ultimately discarded as patient and government pressure forced
managers to move services up and down the list by hand. Whilst results could be said to be modest;
(US OTA n.d., 1992) it did, however, still manage to reduce the amount of people in the state
without health cover from 18% to 11%. (Oberlander, 2001) Also, a more recent Oregon review by
Wilson (2008) discusses at a potential for organisational learning and thus for further improvements,
with time.
Like NICEs decisions, mathematical models would be very important in guiding decisions but PRICEwould also have to take into account issues such as continuing to pay for orphan drugs for rare
conditions and deciding which future treatment look like producing the best results in the future.
(NICE, 2008) Its remit should involve dealing with some very emotive and difficult concepts such as
the fair innings argument (Farrant, 2009), which argues against spending increasing sums on
expanding life beyond a normal span of years, possibly at the expenses of care to the young which
society might value more. (Nord, 1992)
As Williams (2005) reminds us, maximising public health is ultimately incompatible with reducing
equalities as are concepts of choice. Here the perfect would be the enemy of the good and a body
devoted to perusing evidence based rationing would be a big step forward in addressing the many
issues surrounding opportunity cost.
Addressing Overuse, Underuse andMisuse
PRICE would also be tasked with helping ensure allocative efficiency and reduce variation by
implementing the guidance NICE gives and which it deems cost-effective. As the HC (2007, p.80)
identified, better measurement of guidance implementation is also needed. Self-assessment is not
enough. We recommend that the Healthcare Commission conduct more in-depth inspections of this
element of practice.Cooksey (2006) would term this second gap in translation, (see Chart 1 p.8),
and PRICE would need legal powers to enforce decisions here.
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Chart 1: Pathway for Translation of Health Research into Healthcare Improvement
from the Cooksey Review (2006, p.99 )
It is obviously difficult to put a number as to the potential savings here and even if we could quantify
potential it would be difficult to realise; however a number of studies indicate it could be very
substantial. For example, Maynard (2005(b), p.294), citing the work of Fisher, who found that
Medicare expenditure per capita in 2000 varied from $10550 perenrollee in Manhattan to 4823 in
Portland, Oregon.The differential being due to volume effects, independent of differences in the
population studied, which was adjusted for illness rates, service price and socioeconomic status.
Along with how there were potential savings for Medicare of 30% of the budget with no adverse
effects on patient health if high spending areas the reduced expenditure and provided safe practices
of conservative low spending areas.
As the Cooksey Review believed:
To enhance the evidence base informing decisions on the effectiveness and cost-effectiveness
of technologies in the NHS, the Review therefore recommends an expansion of the NHS HTA
programme to fund these developments, which, for a relatively modest investment, could
deliver large improvements in the quality and efficiency of healthcare(Cooksey, 2006 p.102)
Bottom up implementation should not be viewed as the only, or even the best way of realising this
potential. As Berwick (2003) for example highlights, modern theories which utilize the imagination
and participation of the workforce to improve healthcare processes from the bottom up will be
much more effective than older theories which look more to control and standardise from the top
down. Directives such as PRICE are limited in this respect but will strongly signal intent.PRICE would
have to work closely with bodies such as the HTA, Monitor and the CRD, determining which practices
are considered best, disseminate evidence and help guide change from within.
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Helping inform theMedia and Public
Since 2004 NICE has stood for the National Institute for Health and Clinical Excellence; reflecting the
increased need to account for Public Health as part of its remit. (HC, 2007) I was unable to find any
research indicating whether the public at large are aware of this fact, though opinion polls do
suggest that public confidence in NICE is satisfactorily high. (IMC Omnibus Poll 2004 -2007, as cited
in Minhas& Patel, 2008)There is also support from prominent UK medical journals such as the BMJ
and the Lancet have both endorsed the rigour of NICEs methodology and called for the government
to lead a public debate around rationing. (Minhas&Patel, 2008)
PRICE would also be tasked with helping bring this issue further into the public arena. Like with NICE,
government the public and industry should be involved with decisions, press releases be issued
regularly and decisions, with reasoning, be freely available online. A study by Wilson et al., (2008,
p.130) concluded: newspaper coverage of trastuzumab(Herceptin)has been characterized by
uncritical reporting. Believing Journalists (and consumers) should be more questioning when
confronted with information about new drugs and of the motives of those who seek to set the news
agenda.As they discuss the media play an important role in shaping societies understanding about
which decisions are taken regarding cost effectiveness in our NHS. Health resources are not infinite,
more balanced debate here should be encouraged.
Conclusions
Ultimately if the current flat of the curve paradigm continues; with new health technologies
producing marginal benefit at considerable cost, I dont really see any alternative to a body such as
PRICEs creation in the immediate future. As NICE, the HC, the BMJ, the Lancet and numerous
academics highlight, evidence based rationing is the next logical step the NHS needs to take. Whilst
NICE has generally done a good and difficult job to date, in having no remit to tackle rationing it is
now outgrowing its intended purpose. A new body needs to be created to deal with these issues,
with power to enforce decisions legally mandated. I believe it makes sense both politically and
socially for government to be distanced from these decisions to an extent. The sooner it is
implemented the sooner society we will begin to reap the benefits.
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Bibliography
Bernstein, S. Kosecoff, J. Gray, D Hampton, J. Brook, R. (1993) Appropriateness of the use of
cardiovascular procedures: British vs US perspectives. Int J Tech Assess Health Care. 9: 3-10
Berwick, D. (2003). Improvement, trust, and the healthcare workforce.QualSaf Health Care 2003 12:
i2-i6
Birch, S and Gafini, A. (2004) The nice approach to technology assessment: an economics
perspective. Health CareManagement Science 7: 3541
Bloor, K. Maynard, A. Freemantle N. (2004) Variation in activity rates of consultant surgeons and the
influence of reward structures in the NHS: descriptive analysis and a multilevel model. Journal of
Health Service Research and Policy. 9 (2): 76-84
Bryan, S. Williamsa, I. and McIverc, S (2007) Seeing the nice side of cost-effectiveness analysis: a
qualitative investigation of the use of cea in nice technology appraisals. Health Econ. 16: 179193
Cooksey, D. (2006). A review ofUK
health research funding. Downloaded from http://www.hm-treasury.gov.uk/d/pbr06_cooksey_final_report_636.pdf [Accessed December 09]
Davies, P. Lay-Yee, R., Briant, R. (2002) Adverse events in New Zeland public hospitals I: occurance
and impact. New ZelandMedical Journal 115: U271
Devlin, N and Parkin, D. (2004) Does NICE have a cost-effectiveness threshold and what other factors
influence its decisions? A binary choice analysis.Health Econ. 13: 437452
Farrant, A. (2009). The fair innings argument and increasing life spans. J Med 35:53-56
Ferner, R. andMcDowell, S. (2006) How NICE may be outflanked. BMJ 332:1268-1271
Grilli, R, Ramsay, C, Minozzi, S. (2002) Mass media interventions: effects on health servicesutilisation. Cochrane Database of Systematic Reviews; 1 CD000389.
Health Committee (2007).National Institute for Health and Clinical Excellence. First Report of Session
200708. The Stationary Office: London. Available online from http://www.parliament.the-
stationery-office.co.uk/pa/cm200708/cmselect/cmhealth/cmhealth.htm [Downloaded 11th January
2010]
Health Service Journal (2009) NHS cost cutting: how to save 20bn by 2014 10th September 2009.
Available online http://www.hsj.co.uk/5006104.article [Accessed December 09]
Insitute ofMedcine. (1999) The national round-table on health care quality: measuring the quality of
care. Washington: Institute ofMedicine
Maynard (2005(a)) UK healthcare reform: continuity and change In the public private mix for health
pp. 63-83 Radcliffe Ltd: Oxfon
Maynard (2005 (b)) Enduring problems in health care delivery.in The public private mix for health
pp.294- 309 Radcliffe Ltd: Oxfon
8/9/2019 PRICE: Public Rationing and Implementation of Clinical Excellence
9/9
Maynard, A. (2008) Seven years of feast, seven years of famine: boom to bust in the NHS? BMJ
332:906-908
Minhas, R. & Patel, K. (2008) From rationing to rational: the evolving status of NICE. J R Soc Med 101:
436442.
NICE (2008). National Institute for Health and Clinical Excellence: NICE Response to the Committee'sFirst Report of Session 200708 The Stationary Office: London. Available online from
http://www.parliament.the-stationery-
office.co.uk/pa/cm200708/cmselect/cmhealth/cmhealth.htm[Downloaded 11th January 2010]
Nord, E (1992). An Alternative to QALYs: the saved young life equivalent. BMJ 305:875-877
Oberlander, J. Marmor, T. and Jacobs, L. (2001). Rationing medical care: rhetoric and reality in the
oregon health plan. CMAJ , 164 (11), 1557 1648
Pearson, S and Rawlins, D. (2005) Quality, Innovation, and Value for Money: NICE and the British
National Health Service. JAMA. 294(20):2618-2622
RAND (n.d.) (2004) Rand Corporation. The First National Report Card on Quality of Health Care in
America Available from www.rand.org/publications [Accessed 11th January 2010]
Rousseau, D. (2005) Is there such a thing as evidence based management? Academy of
management review 31 (2): 256-259
Rousseau, D. and Mccarthy, S. (2007). Educating managers from an evidence-based perspective.
Academy ofManagement Learning & Education, 2007, 6, (1), 84101.
United States Office of Technology Assessment.(n.d.).(1992) Evaluation of the Oregon Medicaid
Proposal.Available online at http://govinfo.library.unt.edu/ota/Ota_1/DATA/1992/9213.PDF
[Downloaded 11th December 2009]
Walshe, K and Rundall, T (2001). Evidence-based management: from theory to practice in health
care. TheMillbank Quarterly 79 (3) 429-457
Williams, A. (2005) The pervasive role of ideology in the optimisation of the public-private mix in
public health systems. In A. Maynard, eds. The public private mix for health pp. 63-83 Radcliffe Ltd:
Oxfon
Wilson, F. (2008) Oregon Surpasses Struggles of Early Reform and Develops a Road Map for Future
Success Ann InternMed, 149 (2), 149 152
Wilson, P. Booth, A. Eastwood, A. and Watt, I. (2008).Deconstructing media coverage of trastuzumab
(Herceptin): an analysis of national newspaper coverage. J R Soc Med 101:125-132
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