Working with NHS priorities

pharmafile | February 16, 2006 | Feature | |   

Patients, health professionals and even some politicians have said it, now chief medical officer Nigel Crisp has confirmed it in his latest report: NHS managers must not neglect conditions which are not set as NHS priorities.

The goalposts haven't moved. Targets for CHD, cancer, mental health and all the rest set out in the government's 10-year strategy document, the NHS Plan, will still have to be met. But there are a few more obstacles in the way.

Consequently, every bit of help in tackling those priorities, whether from NICE, the independent sector, voluntary sector, or pharmaceutical industry is going to be embraced by managers more passionately than ever.

In his report, published in December, Crisp showed that the NHS is on schedule to meet some of the targets, saying: "Early deaths from cancer, coronary heart disease and suicide continue to fall as services improve".

The report says the NHS is at a turning point. "Over the last five years the NHS has been growing fast, building capacity, it's now important to concentrate more on using it to deliver quality and value for money. Hospital waiting lists are lower, patients have more choice, and new quality standards have been achieved in primary care.

"We are halfway through a ten-year transformation programme. Whilst a great deal has been achieved, there is still much to do. In the mid-term the emphasis needs to be on continuing to innovate and reform to accelerate improvement," says Crisp.

Opening the door

He is in fact opening the door wider for organisations outside the NHS, including the pharma industry, to be involved in changes to services "to achieve improved outcomes and hit government targets".

"Ultimately, success will depend on the people in the NHS and its partner organisations who have so effectively brought improvements in the last five years," he says.

NICE is one of those key partner organisations, and several examples of how it is helping change practice to improve outcomes were showcased at its recent conference in Birmingham.

NICE chair, Professor Sir Michael Rawlins, launching a practical guide on how to implement NICE guidance, said: "We know that the guidance we produce puts additional demands on those delivering services. This guide will describe those core elements known to be important in establishing a successful process at an organisational level, as well as more detailed advice on the steps required to implement different forms of NICE guidance."

Reporting on NICE's progress, he says it has become:

• A trusted source of information and advice for clinicians, patients and the public
• A contributor to post-basic education and continuing professional development
• A global reference – though not a global model
• A standard reference for commissioning and effective investment
• A guide for re-balancing investment between prevention and treatment.

Implementing NICE guidance

Health minister Jane Kennedy told the conference: "The implementation of guidance is still a major issue for both NICE and the Department. Measuring the uptake of guidance is a difficult task and developing measures to reduce variability of uptake is even more so."

She said the Department treated the implementation of NICE guidance "as an ongoing priority" and gave a great deal of consideration to new evidence on its uptake, such as the recent Audit Commission report.

"The Department is continuing to work with NICE to ensure that uptake of the Institute's recommendations is as universal as possible," she added.

In addition, she warned: "It is not acceptable for the local NHS to cite a lack of NICE guidance as a reason for not providing a treatment. A key role of the NHS has been, and will continue to be, to make decisions about the use of new pharmaceuticals. NICE does not exist to 'kitemark' all the drugs which are licensed in the UK. Therefore, the NHS will have to make informed decisions about the use of these drugs.

"Drugs cost money, this is accepted, but the NHS has to decide which represent an effective use of resources and which do not. A patient should not be refused a treatment just because it 'costs'. Consideration must be given to the effectiveness of the treatment, having looked at the available evidence."

Dr Mayur Lakhani, chairman of the RCGP, said: "Patients expect all their problems to be dealt with, not just ones which feature in a contract or are 'flavour of the month'."

On implementing NICE and other guidance, he said: "Clinical guidelines can and do make a difference – the key question is how to get a greater effect."

Every consultation with primary care is an opportunity for implementation, but he pointed out: "Co-morbidity is the rule. Many guidelines are single disease topics and derived from trials done in selected populations."

He said the NHS had a duty to ameliorate health inequalities and there should be a priority for implementation in disadvantaged areas. But he added: "A contract will never be enough to implement all the best practice."

Martin Ferris, South Yorkshire SHA pointed out that not everyone wanted to take the same route in implementing NICE guidance. Sheffield had put its own model together which was straightforward, well structured, relevant, valid, suitable for use by all trusts across the country and was consistent with national developments.

It had received very positive feedback, but Ferris stressed effective dissemination to all professional groups was essential, saying: "You can't implement what you don't know."

Using registers

Another tip for commissioners checking effectiveness and outcomes before contracting to meet targets, was the use of registers. They could be helpful, but John Nichol, Medical Care Research Unit, ScHARR, University of Sheffield, warned: "Though they can be useful for many purposes, they never work without clinical ownership, and they can't work without proper resourcing."

He said quality was the key, and to be useful at all, registers must: include individual data on consecutive cases (no selection); have full, standardised follow-up; accurate recording; and include all known characteristics affecting outcome.  

One example of a register being used to implement guidance was given by Jane Hanna, from the charity, Epilepsy Bereaved, talking about best practice in implementing NICE guidance on epilepsy. She said that since the new GP Contract, many practices had introduced epilepsy registers under the umbrella of the quality outcomes framework.

She said they were important in getting the right diagnosis, especially as 20-31% of people with epilepsy were misdiagnosed and on the wrong medication.

Priority medicines

A European and global slant on priority medicines was given by Richard Laing, medical officer, policy, access and rational use, medicine policy standards, World Health Organisation who helped prepare a report for the Netherland's government on the subject.

"Good public policy should spend public funds on areas of greatest public needs," he said. The objectives of WHO's Priority Medicines Project was to:

• Provide a methodology for identifying pharma gaps from a public health perspective, for Europe and the world
• Provide a public health-based pharma R&D agenda for use by the EU in the 7th Framework Programme

Priority medicines could also be classified as 'medicines which are needed to meet the priority healthcare needs of the population but which have not yet been developed'.

A 'pharmaceutical gap' could be defined as: 'when a treatment for a disease or condition does not yet exist or will become ineffective soon, or is available but the delivery mechanism or formulation is not appropriate for the target patient group'.

Global health threats

He said pandemic influenza was a global public health threat. We were overdue for a new pandemic, the uptake of existing vaccines is poor, and our current capacity to produce either vaccines or antiviral medicines was not sufficient.

Another global public health threat was the rise in antibacterial resistance and the decline in innovation. The low burden in Europe removed the incentive for R&D, and he warned: "Little R&D on antibacterials will have consequences for future generations with the global increase in the spread of drug-resistant bacteria." He pointed out:

• A commonality of interest exists for chronic diseases between Europe and the world.
• Priorities can be set based on evidence, trends and projections and social solidarity.
• Pharmaceutical gaps exist as a result of biological challenges and market failure.
•  Highest priorities are antibacterial resistance, influenza, cardiovascular disease and neglected diseases.
• Pricing issues and barriers to innovation strongly affect the European industry.
• The EU needs to find a way to support translational research for market failure pharmaceutical gaps.

He said there was lack of EU support for translational research for market failure diseases. 'Neglected' diseases included:

• Malaria: lack of experimental models for medicines discovery an development.
• Tuberculosis: More FDCs for second-line treatment of multidrug-resistant TB and diagnostics.
• Leishmaniasis, trypanosomiasis, Buruli ulcer: Most of the medicines being used are old and often dangerous.
• Post-partum haemorrhage: Major cause of maternal mortality in developing countries  heat stable oxytocin would be a major advance in public health for women.

He said there was a high burden of diseases where existing therapies could be improved, including cancer and diabetes, and depression in adolescents and elderly people.

Existing antidepressants work well for adult depression, but there were gaps in understanding the biology of depression and its treatments in these groups.

Women, children and elderly people as groups were all neglected in drug development partly because of complications by different physiologies and metabolisms. Although there had been some recent improvements in the situation of women and children, considerable gaps still remained for the elderly who used the most medicines.

Another area for improvement was the secondary prevention of cardiovascular disease and stroke. There was good evidence to show that patients with a heart attack or stroke could reduce their risk of a repeat attack by 66% by taking four medicines, but uptake was slow (less than 20%).

He said the 'polypill' using fixed dose combination (aspirin, statin, ACE inhibitor and beta-blocker or thiazide diuretic) deserves further, urgent study.

Dr Fiona Adstead, deputy chief medical officer, commenting on delivering the Public Health White Paper Choosing Health and its targets, warned of a slowdown in new NHS funding for growth of services, but there would be increased cross-sector provision from local government.

She said there would be a developing role for NICE in the translation of national goals into effective health support for commissioned care through:

• Evidence of effective interventions and strategies for stopping ineffective interventions
• Prevention integrated into all NICE outputs, not just public health guidance
• Increased productivity from available NHS resource

Bruce Campbell, chairman, NICE Interventional Procedures Advisory Committee, said NICE had a commitment to the concept of national registries, because of the inadequate evidence of many procedures – there was an increasing problem with newer procedures and there was seldom any defined facility for audit.

He conceded they were not good for clinical effectiveness, and there was limited information on efficacy, but they were good for safety. The aim of IP registries was to:

• Collect information rapidly on 'high impact' procedures
• Collect information gradually on 'orphan' procedures
• Provide evidence for IP guidance
• Define focus for audit
• Provide valuable data for publication.

The DH will soon publish a framework for the NHS setting out how the reforms fit together, and the next steps in the implementation timetable.

The White Paper on health and social care in the community will be based on consultation on the earlier Green Paper on social care, Independence, Choice and Well Being, and the recent consultation: Your Health, Your Care, Your Say.

"It will strengthen and reinforce the overall direction and bring together our approach to health, health services and social care," said Crisp.