3 min read

The Maynard Doctrine: NICE troubles to have

Profesoor Alan Maynard wonders what the changes to NICE’s remit mean for rationing.

Just what do the Con-‘em Coalition plan to do with NICE and the market for pharmaceuticals?

Firstly we have Cameron’s “Cancer Drugs Fund”. This was a bag of NHS swag used to buy votes in the election by pleasing both cancer patient groups and the merchants of inefficient and highly expensive cancer drugs to which NICE had said no.

Now the poor civil servants are trying to work out how to spend this money. Their political masters are rightly being asked, why do you favour this one disease?

Why not mental illness, diabetes or cardiac care? Given pharmaceutical developments, surely diabetes will be next to have a special fund; as marginally efficient expensive drugs are appearing there too now.

The next event began with speeches and briefings last week Earl Howe, a junior bag carrying minister, speaking to a conference of drug dealers and reported in Pharma Times to the effect that NICE could no longer say no to new drugs being reimbursed by the NHS.

This was translated as the abolition of NICE, to which the Department of Stealth said perish the thought! NICE will continue to provide guidelines, but treatment decisions will now lie with clinicians.

All hail clinical autonomy
All praise to the God of “clinical autonomy” eh? John Hampton, an eminent cardiologist, wrote that clinical autonomy is dead and no one should mourn its passing in the British Medical Journal in 1983. Clearly, Her Majesty’s Government is somewhat behind received clinical opinion.

Most doctors want guidance and advice on how to ration access to NHS care. This is a very difficult part of their job, and fragmentation of these processes with lead to a bonanza of “postcode rationing” drivel!

At present, most rationing takes place in clinical settings and in primary care trusts, soon to be replaced by GP commissioning consortia.

NICE deals only with expensive new (largely pharmaceutical) technologies. It has tended, under enormous pressure from industry, to be generous in its decision-making and used a rationing cut off that is much higher than that used by PCTs (£30,000 per QALY).

’NICE has contributed little to containing NHS expenditure

NICE has contributed little to containing NHS expenditure. Indeed, its generous decisions have added billions to NHS expenditure. This was all very nice during the Blair-Brown spending period.

Tighter times
But now we need rationing information and a greater curb on keeping the ever-grasping drug dealers in the style to which they are accustomed!

Ah! Lansley them briefs some journalists last week and says that at the end of the current Pharmaceutical Price Regulation Scheme (PPRS) period in 2014, they will introduce value-based pricing (VBP).

PPRS has kept the industry investing in British jobs and science for over 50 years, offering a target rate of return of 20 per cent on historical capital. Nice if you can get it.

Will VBP be less generous? Pigs may fly!

The inclination of successive governments is to protect the drug industry to enhance employment and export income. Regulation is always and everywhere used by industry and government to limit competition and enhance profits of potential industrial supporters.

Cheaper drugs benefit a dispersed group of people who cannot be easily tapped for electoral support. Being “good” to industry and patients groups mobilises the NHS user groups, which are funded by the drug dealers. It is a neat way of targeting electoral support.

Price based on whose value?

’The fundamental issue with VBP is who sets the price and how’.

The fundamental issue with VBP is who sets the price and how. Will VBP be conducted by a vigorous evidence-based offspring of NICE? Or will there be industry capture of VBP and defence of their profits?

Somewhere in Whitehall, such issues are no doubt being considered. The NICE-ites are seeking to maintain their role; whilst Ministers hint they are doomed, but do not clarify what they mean by “doom”!

Industry is praying that NICE is to be undermined and be less of an (all too minor) block to their marketing marginally efficient drugs. They twitter that UK drug prices influence overseas prices and sales and that nicely inflated NHS prices generate the golden prosperity promised by the Coalition!

What has happened in the last week is the first act of a fascinating play. Those interested in the use of science as a means of informing difficult rationing decisions by clinicians will hope that patient interests will be to the fore rather than part of political rhetoric.

But hope can only be translated into reality by stubborn resistance to those fixated with profiting from “innovations” of often limited clinical and cost effectiveness.