Interview with Gillian Leng: Health Technology Assessment is central to access and equity

17th June 2015

There may be a perception that health technology assessment is solely concerned with rationing the use of innovative drugs, but in fact, the opposite is the case, says Professor Gillian Leng, Deputy Chief Executive of the UK National Institute of Health and Care Excellence. Rather, the aim is to actively promote uptake of treatments that are good value for money

In common with health technology assessment (HTA) bodies across Europe, the UK National Institute for Health and Care Excellence (NICE) takes a technical approach to assessing drugs and treatments, in order to secure the widest possible access at the best price, and so get the maximum ‘health’ value for the available budget.

“NICE’s methodologies test that treatments are both clinically-effective and cost-effective,” says Professor Gillian Leng, Deputy Chief Executive and Director of Health and Social Care at NICE. The process involves a comparison of how well a treatment works compared to the available alternatives.

Drugs or treatments that are expensive and which do not demonstrate a significant benefit are unlikely to get NICE approval for use in the National Health Service (NHS). However, if a pharmaceutical company feels that accumulating further clinical data would allow a product to demonstrate its value it can propose a Patient Access Scheme, under which, in effect, the company assumes a greater share of the risk. Examples range from simple discounts, to capping the number of doses or the NHS paying only for patients that make a specific clinical response to a drug.

Overall, “The aim is always to get access at the lowest cost – but it doesn’t always happen – the NHS cannot afford every new treatment,” Professor Leng says.

The other side of the HTA coin

So far, this reads as a familiar tale of HTA not being able to ascribe the true value to innovation. But while some rationing is inevitable in any health system, this is a small part of the picture. “The more significant point is that NICE has a remit to actively promote access when a treatment represents good value for money,” says Professor Leng.

Beyond issuing its guidance recommending use of effective and cost-effective drugs –which requires funding from all regional and local health bodies – NICE also helps to track uptake, via an innovation scorecard. This allows patients and the public to see which health bodies are adopting the latest NICE-approved treatments and drugs most quickly.

In addition, there is a scheme to help local NHS organisations implement NICE guidelines and promote the exchange of best practice. The objective is to reduce unwarranted variation in uptake, which can lead to inequity in access between one part of the country and another.

“There are some really good examples where NICE has said yes to an innovative treatment but uptake has been patchy, and tracking has promoted change,” Professor Leng says.

One case in point is NICE’s recommendation that novel anti-coagulent drugs are a cost-effective option, which could replace the use of Warfarin. Although an effective drug with a long history of use in the prevention and treatment of thrombosis, patients taking Warfarin need to be monitored regularly to see how long it takes for their blood to clot and ensure they get an effective yet safe dose.

The new anti-coagulant drugs recommended by NICE do not require monitoring, representing greater safety and convenience for many patients and potentially saving resources for providers. “You would have thought it was easy to put the NICE recommendation into practice,” says Professor Leng. However, the existence of specialist Warfarin clinics complicates things. “It’s not just a case of making the recommendation and changing the prescription: you need a system redesign,” she says.

The need to restructure and change practice in order to realise the full value of innovation, is often overlooked. “In general, health systems do not invest in this,” Professor Leng notes.

Integrating health and care

This presents a particularly big hurdle for attempts to integrate health and social care, a move that is seen as central to improving sustainability and ensuring access across Europe.

While all healthcare is free at the point of delivery in the UK, social care is means tested and only 50 percent of provision is free. “Health and social care services should be meshed together,” says Professor Leng. However, at present there are not many good examples of this happening in the UK. “The fundamental difficulty is not just who holds a particular budget, but who can access it.”

Other problems that need to be dealt with include different information resources, different training content and differing skills levels between health professionals and care professionals.

However, integration is on the agenda, as illustrated by the addition of the word ‘care’ to NICE’s title following the enactment of the Health and Social Care Act 2012. “Where previously we looked at long-term conditions from the clinical perspective, we can now extend the guideline scope into care. This should help integration at the system level,” says Professor Leng.

One example is in multiple sclerosis. “Previously our guidance was only clinical, which many patients thought was limiting.   Now the scope can cover social care, and there is a benefit for patients in terms of accessing the services they need, and for providers, who can set up integrated clinical/care pathways.”

Professor Leng points to another challenge that emerges here, in that NICE needs to reach a much broader audience. “Clinical guidelines are relatively straightforward to disseminate, via healthcare providers and clinical professional groups. Within the UK care system there are a number of audiences.” These include a large number or private providers, local authorities that commission care and the general public who often self fund their care.

While there is a long way to go, Professor Leng believes there is some momentum, pointing to a number of large scale practical projects that will be test cases for integration, notably in the city of Manchester, and the fact that the regulatory body, the Care Quality Commission, has said it will use NICE’s integrated guidelines to inform their inspections.