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Reducing the length of time that patients with cancer spend in hospital would free finance for expensive cancer drugs, says the national director for cancer services in England.
Mike Richards, England's cancer tsar, made the suggestion at the opening session of the second parliamentary inquiry into the National Institute for Health and Clinical Excellence (NICE) since the institute was set up in 1999.
NICE has been criticised recently by patients and drug companies, the House of Commons health select committee reported. NICE's refusal to provide the data that led to its decision to refuse to recommend certain drugs for Alzheimer's disease has even prompted a judicial review, which will take place next month.
Professor Richards said that advances in drug technology offered a “very exciting time” for the treatment of cancer, and more than half of the new drugs currently being developed are related to cancer. “We have a new generation of drugs that are targeted at specific cancers. Clearly that puts pressure on budgets.”
When asked by Howard Stoate, MP for Dartford, whether the current system could cope with such high spending on cancer, he responded, “No, we are looking very carefully at what we are spending but the largest single expenditure on cancer is actually on inpatient care, not on drugs.”
He said that the United Kingdom kept patients with cancer as inpatients far longer than hospitals in other European countries. “If we can bear down on that, we can create more headroom for extending budgets,” he said.
Other ways to improve cost effectiveness included benchmarking spending by different primary care trusts (PCTs), re-examining the care pathway, and looking at spending more on prevention and early detection.
When asked how the NHS could make progress with getting clinical guidelines implemented as well as guidance on drugs, Professor Richards admitted this was difficult with such lengthy documents. Measurement would help, he said, as would ensuring that primary care trusts got feedback of information on their progress.
One clinical guideline for which little progress seems to have been made, anecdotally at least, is the one on fertility, said MPs.
In 2004 NICE recommended that infertile couples should get three free cycles of in vitro fertilisation treatment. Realising the financial pressures that this would place on the NHS, John Reid, then health secretary, reduced this to one cycle, announcing that all primary care trusts must comply with at least one NHS cycle by April 2005.
Kevin Barron, MP for Rother Valley and committee chairman, told the inquiry that he knew of cases in which trusts were not providing even one cycle. Two other MPs said the same.
“What action has the Department of Health taken for those that are not even doing one?” asked Mr Barron.
“We will look at this and can provide further information for the panel on this,” said Felicity Harvey, head of medicines, pharmacy, and industry for the Department of Health. “This is where we would expect strategic health authorities to take management action.”
“I am quite astonished at the complacency of the Department of Health,” said Mike Penning, MP for Hemel Hempstead. “PCTs have not got the budgets to implement some of this NICE guidance and instead of answering the question you have gone on about public health. What are you going to do about this variation?”
Ms Harvey said that the government was working with Infertility Network UK and trusts to try to improve implementation of the recommendations.
The Healthcare Commission told the BMJ that the penalty for trusts' non-compliance with NICE guidance was a lower score in performance ratings in the commission's monitoring system, the “annual health check.”
“Eradicating inappropriate variation is actively a challenge for every healthcare system,” admitted Professor Sir Michael Rawlins, chairman of NICE. “The Germans thought they had a uniform system till they started looking. The United States says it has just as much variation as we have, and they have twice as much money.”
From the autumn, NICE's proceedings on how it makes decisions about what the NHS should fund will be held in public rather than behind closed doors, he added, in an effort to further boost transparency.
Proceedings of the House of Commons health select committee inquiry into the National Institute for Health and Clinical Excellence are available at www.parliament.uk.