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The challenge of

disinvestment
Kalipso Chalkidou
Research and Development
NICE

ESRC Seminar Series; March 2007


Good intentions
• “With all the excellent developments in medicine that are
becoming available, it is not in anyone's interest to waste money
on treatments that do not provide good value for money […]
NICE is going to provide authoritative advice to help us make
the best use of the resources available to the NHS.”
Frank Dobson, Secretary of State for Health, speech launching NICE, March 1999

• ACTS Definitions and Criteria: “Does the proposed guidance


relate to one or more interventions which could, without
detriment to patient care, be used more selectively, thus
freeing up resources for use elsewhere in the NHS?”

ESRC Seminar Series; March 2007


Limited impact?
• There are some good examples:
– appraisals on the removal of wisdom teeth and proton pump inhibitors;
– guidelines• on the management of heavy menstrual bleeding, caesarean section and LARC
National tariff uplift 2005/06: £389m (+0.9%)
but… •Specific adjustments to HRGs
• Clear bias in favour of new technologies
• Few “disinvestment” topics actually
approx referred to
£800-1,200m NICE impact
overall
• Rationale for referral not explicitly stated in the guidance remit
• Limited evidence base for established treatments
• Resistance to withdrawing existing technologies

ESRC Seminar Series; March 2007


Waste not, want not
• “NICE should be
asked to issue guidance to the NHS
on disinvestment, away from established
interventions that are no longer appropriate
or effective, or do not provide value for money.”
CMO Annual Report, 2005

• "NICE has an excellent track record in identifying and


recommending the most effective new treatments. But we need to
ensure that we balance this with better advice on unnecessary and
ineffective interventions that can be stopped."
Andy Burnham, Sep 2006

ESRC Seminar Series; March 2007


Can cost inflating be cost-effective?
1. Develop cost-effective public health guidance: reduce clinical need: “fully
engaged scenario”
2. Set realistic threshold reflecting ICERs of services currently introduced or
discontinued at the local level, assuming a rational prioritisation process, informed
by economic evidence, exists
3. Identify, evaluate and recommend against ongoing cost-ineffective practices: set
up a disinvestment agenda
4. Influence strategic research priorities to reduce uncertainty and prevent
decision reversal and sunk costs

ESRC Seminar Series; March 2007


NICE disinvestment activities
• Recommendation reminders
• Commissioners’ guides
• Using existing NICE programmes
• Establishing dedicated disinvestment streams
• Topic selection
• A disinvestment related research agenda
• Working with external partners

ESRC Seminar Series; March 2007


Recommendation Reminders
• Existing NICE guidance
• Still relevant to the NHS: clinical expert input
• Additional costing tools
• Over 250 single “do not do” recommendations between 1999-
2005

• Lesson 1: the press release matters!


• Lesson 2: baseline hard (impossible?) to define; lack of data
• Lesson 3: some people do not want to be reminded…

ESRC Seminar Series; March 2007


Commissioners’ Guides
• Not dedicated disinvestment tool
• Aimed at supporting evidence-based effective commissioning
• Building on NICE costing tools/budget impact analysis
• Examples: upper GI endoscopy, foot care for diabetes,
anticoagulation, management of COPD
• Commissioning guides are not:
– advice on how to commission
– new formal NICE guidance
– fixed: can be adjusted to local setting
• Web-based; accessible to PCTs and practices in England

ESRC Seminar Series; March 2007


Topic selection
• Increased responsibility of NICE in topic selection
• No separate disinvestment consideration panel
• Consider:
– variation in practice,
– current usage and potential real savings,
– substitute technology/pathway,
– feasibility of change in practice,
– effect on inequalities(?)
• Sometimes, disinvestment topics result in investment
recommendations…

ESRC Seminar Series; March 2007


Using existing NICE programmes
• Target wasteful practice at the scoping stage
• Encourage guidance developers to think about waste
• Improve communication of “do not do” recommendations
• “PET, structural MRI, magnetic resonance volumetry and
magnetic resonance spectometry should not be used in the
differential diagnosis of parkinsonian syndromes, except in the
context of clinical trials.” Parkinson’s disease, NICE Clinical Guideline, London,
June 2006
• “The use of multi-channel cystometry, ambulatory urodynamics
or videourodynamics is not recommended before starting
conservative treatment.” The management of urinary incontinence in women,
NICE Clinical Guideline, London, October 2006

ESRC Seminar Series; March 2007


New disinvestment streams
• Same methodology of economic evaluation
• Focus on identification of relevant topics
• Key areas:
– Service reconfiguration – but the evidence base is different
– Inappropriate use of antibiotics: chloramphenicol for conjunctivitis,
tetracyclines for acne and topical corticosteroid/antimicrobial
combinations
– Grommets
– Diagnostic tests

ESRC Seminar Series; March 2007


Research and disinvestment: atopic
eczema
What we said:
• It is recommended that topical corticosteroids should be
prescribed for application only once or twice daily.
What we do not know:
• Is once-daily use of the older twice-daily products equivalent to
the once-daily-only products of the same potency?
What we said:
• Topical tacrolimus and pimecrolimus are not recommended for
the treatment of mild eczema or as first-line treatments for
eczema of any severity.
What we do not know:
• What are the long-term effects of tacrolimus and pimecrolimus?
• How do these drugs compare with appropriate potencies of
topical corticosteroids?
ESRC Seminar Series; March 2007
Cooksey Report
• “The Review recommends that funding be identified
and formal arrangements be established between
NHS R&D and NICE in order to implement NICE
recommendations calling on the NHS to use health
interventions in a research context”
– Value-based pricing for new technologies
– Continuous evaluation through registries and databases for
established treatments
– Implementation of public health and clinical guidelines
recommendations “only in research”
– Methods for developing disinvestment guidance

ESRC Seminar Series; March 2007


Partner organisations
• Cochrane Collaboration
• Association of Public Health Observatories
• NHS Institute
• NHS information centre and other databases
• Welsh HIRU
• …

ESRC Seminar Series; March 2007


The challenges of substitution

ESRC Seminar Series; March 2007


Evidential and methodological…

• Selecting the right topics


• What is the comparator?
• Weak evidence base for established treatments
• Guidance developers reluctant to stop current practice
• No “sponsor” and little incentive for more research
• Are savings real(isable)?
– Economic vs costing model; defining opportunity cost
– Extrapolating over long time horizons
– Establishing the baseline

ESRC Seminar Series; March 2007


Implementation…
• What happens with the savings: Choosing Health vs
chemo?
• The “kinkiness of the SW quadrant”
NICE-specific
• Centralised advise often insensitive to local setting
• NICE does not look at everything; what about
activities below the baseline?

ESRC Seminar Series; March 2007


and other!
• Single technology appraisal: getting the
comparator/timing right
• Substituting new technologies for preventative
interventions: lowering the threshold?
• 3 month implementation directive and the health-
wealth trade-off

ESRC Seminar Series; March 2007


Way forward
• NICE can:
– Help manage pressures
– Trigger a public debate and help bring about a mentality change
– Encourage necessary research and evidence generation
– Produce more evidence-based disinvestment advice and less
budget-inflating recommendations

But we can do more…

ESRC Seminar Series; March 2007


How can NICE really add value?
• Empower commissioners and consumers (PCTs, GPs…patients)
• Provide access to:
– evidence-based
– need-adjusted
comparative rates for benchmarking
• Elicit patient and professional input
• Move away from centralised intervention-specific “do not do”
guidance
– commissioners' guides
– tailored guidance (?)
– evidence base for “contract exclusion” agenda (?)

ESRC Seminar Series; March 2007


It’s the data,…!
surgery drugs diagnostics disease management prevention health promotion
NICE guidance

1. Topic selection BoD, variation, evidence base, trend data


2. Scoping Prevalence/incidence, current practice, comparators

3. Guidance
Guidance development stages Baseline risk, resource use, QoL, long-term follow up,
development subgroup analysis, generalisability of effect…
Ongoing studies, “only in research” when high
4. Evidence gaps
uncertainty, high priority research questions
5. Budget impact Unit costs, PCT/SHA demographics, service activity,
prescribing and workforce data

6. Implementation Examples of good practice, existing networks, relevant


support policy initiatives

7. Guidance review New evidence on long term costs, efficacy, safety,


alternatives
8. Guidance uptake
and impact Prescribing (by indication) and activity data, barriers,
frontline substitution threshold, relating spending
assessment
to health outcomes
Lack of data…still useful?
• Evidence of lack of
effectiveness vs lack of
evidence of
effectiveness:
– Inform strategic
research priorities
– Support
commissioning

ESRC Seminar Series; March 2007


CEA in the NICE context is not a
panacea…
We need access to longitudinal data on variation* coupled with
robust local prioritisation processes
*Fisher et al, Ann Intern Med, 2003; Skinner et al, Health Affairs, 2006

“NICE has operated during the halcyon days of an


unprecedented period of sustained growth in the overall NHS
budget, a rate of growth that cannot continue indefinitely. When
budgets cease to grow, a new day will dawn for NICE and the
NHS as they manage the delicate balance between cost-
effective new technologies and local health authority budgets.”

Pearson and Rawlins, JAMA, November 2005

ESRC Seminar Series; March 2007


Thank you!
ESRC Seminar Series; March 2007