The NICE challenge

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The NICE challenge
Managing scarcity in the NHS Building on
theory Learning from practice

• Dr Gillian Leng, Implementation Systems Director,
  
• Jennifer Field, Associate Director costing
• NICE

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NICE
Guidance
Plan
Support
Implement/ commission
Audit
Feedback
External organisation
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Areas to cover

• Guidance development
• Economic challenges in STA and public health
• Implementation support
• Cost impact and links to HEA
• Commissioning support
• Feedback
• Implementation in practice barriers and
  successes

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Guidance development
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Centre for Health Technology Evaluation -
technology appraisals - interventional procedures
Centre for Clinical Practice - clinical
guidelines
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Technology appraisals

• Taxanes for breast cancer
• Laparoscopic surgery for hernia
• Glitazones for diabetes
• Electroconvulsive therapy
• Orlistat for obesity

• Guidance on the clinical and cost-effectiveness
  of specific new or existing medicines and
  treatments leading to recommendations on the
  appropriate use of the technology on the NHS

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New single technology appraisal process

• New, shorter process, for single technologies for
  single indications
• Will retain current process for multiple
  technology (e.g. drug class) appraisals
• Recommendations issued close to point of
  introduction into the UK
• Key principles maintained
• Transparency, inclusiveness, robust assessment,
  independent decision making, regular review

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STA process elements

• Minimum timeline of 6 months overall
• Reliance on standard template company submission
• Option to include consultation (i.e. current
  appraisal consultation document stage) where the
  Appraisal Committees recommendations are
  substantively restrictive relative to the
  licensed indication
• Appeal stage retained in every case

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Evidence Review Group

• Commissioned by National Collaborating Centre for
  Health Technology Assessment
• Undertake a technical review of the
  manufacturer/sponsor evidence submission
• Remit
• Critically evaluate submission
• Identify gaps in the evidence base that may lead
  to the Institute seeking clarification from the
  manufacturer
• Prepare a report for the Appraisal Committee
• Will not generally perform extra analyses
  independent of clarification.

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PH intervention guidance

• Sensible drinking
• Workplace health promotion
• Promotion of mental well-being in primary schools
• Strategies for reducing the harm from smoking

• Locally delivered circumscribed activities that
  help reduce the risk of developing a disease or
  helps to promote a healthy way of life
• Relatively limited in terms of reach
• Downstream focus

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Evolving thinking.

• PHIAC makes decisions about PH interventions
• In this environment, decisions are made that are
  not based on evidence backed by 95 confidence
• Additionally, cost-effectiveness decisions do not
  have to be backed by 95 confidence
• This conflicts with the traditional statistical
  approach

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Example physical activity

• Patients who are overly sedentary may be referred
  to an exercise programme
• Evidence of effectiveness of these programmes is
  inconclusive
• One good quality RCT shows no significant benefit
  after 6 months (95 level) but the level of
  benefit at 12 months is in the right direction
  (significant at the 50 level)
• Three poor quality RCTs also show no significant
  benefit

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Example physical activity

• How PHIAC looked at this problem
• Exercise is good. It has been proved with much
  more than 50 effectiveness
• The effectiveness of the exercise referral
  programme has therefore been proved
• It is the cost-effectiveness of the delivery
  system that must be examined
• The emphasis has therefore changed it is
  removed from effectiveness and goes straight to
  cost-effectiveness

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Implementation support
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Practical implementation support

• Context health service funding and
  commissioning in England
• Tools provided
• Forward planner
• Slide sets
• Implementation advice
• Costing tools
• Commissioning tools

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Costing tools

• Managers and clinicians often cite funding as a
  barrier to implementing NICE guidance
• A review published September 2005 demonstrated
  that some NHS bodies did not have a systematic
  approach to planning and costing impact of
  forthcoming guidance
• Tools aim to assist with the planning and costing

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What is cost impact?

• Micro level
• Health economics compares treatment A with
  treatment B leading to recommendation X

• Macro level
• Cost impact estimates the effect of implementing
  recommendation X within target population.

Cost impact cost of optimum care less cost of
current care It can be either a cost (), a
saving (-), or cost neutral, but involve the
redirection of resources
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Costing tools produced (clinical guidelines)

• There are two main outputs

1. National cost impact report
2. Spreadsheet template to help assess local
impact
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Cost impact How is it done?
Identify Significant Cost Impact Recommendations
Guidance at 1st Consultation Stage
Develop costing model
Draft national report
Develop local template
Targeted consultation
Check against final guidance
At same time as guidance
Publication
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Costing template

• Step one select local population
• Step two review detailed assumptions and tailor
  for local circumstances
• Step three review summary

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Cost impact analysis the challenges

• Clinical and cost information can be limited
• Unable to build comprehensive bottom up model
  of costs some generalisation inevitable
• Need for pragmatism and development of
  assumptions, which need to be tested
• Focus on key cost drivers, not the entire
  guideline

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Cost impact analysis the benefits

• Consideration of cost impact as part of
  implementation planning contributes to meeting
  Standards for better health
• Flexible local template is important tool to
  encourage communication between
• Commissioners and providers
• Clinicians, implementers and finance staff
• Implementation leads to improved patient care,
  that is consistent

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Vision for commissioning guides

• To provide commissioners with an intuitive,
  interactive, web-based tool to enable them to
  assess what they need to do to move their
  services towards compliance with NICE and to help
  them with the preparation of a business case for
  change.

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Underpinning principles

• Based on NICE guidance
• No new recommendations
• Provides links to other sources of information
• Not aiming to provide generic advice on how to
  commission
• Gives links to local data with costing
  assumptions
• Not fixed all locally modifiable
• Aims to inform local planning
• Not formal NICE guidance

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Two phases

• Phase 1
• Autumn 2006
• 5 topics
• Static data to facilitate needs assessment
  analysis and costing

• Phase 2
• Dependent on evaluation of the pilot
• May contain more comprehensive topic areas and
  have direct access to live data sets

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Topics for autumn 2006
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Upper GI endoscopy headings

• Commissioning an upper GI endoscopy service
• Specifying an upper GI endoscopy service
• Referral criteria for upper GI endoscopy
• Determining local service levels for upper GI
  endoscopy
• Benchmarks for a standard population
• Assessing and costing local provision
• Calculate the upper GI endoscopy rate in your
  area
• Calculate the number of endoscopies to commission
• Calculate the resources you will need
• Ensuring corporate and quality assurance

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Commissioning - next steps

• Publish next 4 guides!
• Obtain feedback from end-users
• Identify topics for future guides
• Revise model in line with evaluation
• Plan to develop 10 each year

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Evaluation of other tools

• Responsive to ad hoc feedback
• Workshops held July 2005 and Dec 2005
• Two more workshops to be held Nov/Dec 2006
• Audit tools to be evaluated next Spring

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Feedback
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What impact is NICE having?

• Effective monitoring is required
• Feedback obtained from a range of sources

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Challenges to uptake

• Topic relevance
• Volume of guidance
• Organisational issues
• Clinicians acceptance
• Funding (or lack of it)

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Appraisals what do the data show?
Self assessment results NHS Trusts
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Hip disease replacement prostheses

• NICE recommended
• Wherever possible, the NHS should use
  artificial hip joints that can show they last for
  10 years or more.
• Dr Foster guide 2005
• All but one hospital in Scotland and 89 per
  cent of hospitals in England use approved hips.

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Implementationconsultants
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Uptake of drotecogin alfa
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Uptake of anti-obesity drugs
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Future challenges

• Methodological issues
• STA and PH guidance
• Volume of guidance
• Communication and implementation
• NHS reorganisation
• Independent NHS?
• Political/policy changes
• New government?
• Range of audiences
• NHS and public health

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www.nice.org.uk Gillian.leng_at_nice.org.uk Jennifer.
field_at_nice.org.uk