NICE: Postcode Prescribing, Diabetes Updates, and AI

Tim Locke

Disclosures

November 16, 2018

Ever wondered how NICE puts together its guidance and then keeps it up to date?

Dr Paul Chrisp, director, Centre for Guidelines at the National Institute for Health and Care Excellence has been explaining the scale of its work to the Diabetes Professional Care conference at Olympia in London.

   

Dr Paul Chrisp

He told delegates how diabetes is to feature in pilots on improved 'pathways' in its guidance, with the promise of further details at the NICE conference in May 2019.

Medscape UK talked to Dr Chrisp after his session.

Growing Public Health Issue

Dr Chrisp: Diabetes is such a big public health issue. It's been on our radar since 2004 (NICE has been around since 1999) and clearly that issue is getting bigger. So it occupies a large part of our portfolio.

We have over 60 pieces of guidance and advice and standards. Now each of those has been developed with a specific goal in mind, which makes sense.

Some are bigger than others. So managing adults with type 2, adults with type 1, they're the big foundations, but then there are other areas, such as diabetes in pregnancy, or managing the diabetic foot.

Guidelines are referred to NICE by the Department of Health and Social Care or NHS England because they're seen to be an area where there's a gap.

So that's what drives our guideline programme. With the technology appraisals for new drugs or devices, again, those are referred to us.

The breadth reflects the demand and the priorities that [the] healthcare system recognises.

If you do a search on the NICE website using 'diabetes' you get 147 hits.

I think we've got it all covered. But it may be hard to navigate.

Keeping Guidance Up-to-Date

Dr Chrisp: Whenever you produce a new guideline, you have to feed it, you've got to keep it up-to-date. Sometimes we do stand our guidelines down, or stand down different recommendations.

Some areas are more dynamic than others, clinically, therefore, there will be a disproportionate amount of effort. So we always look at least every 5 years at every guideline.

That to me, seems like quite a big time lag. So what we also do is we are driven by events. For example, a new piece of evidence, a big clinical trial, or maybe some audit data, or maybe there's some safety advice about a medicine. With these things, we don't wait for 5 years, that would be crazy. We trigger a quick update.

Now, when we say quick currently, that might still take 6 to 2 months.

What I'm keen to do, coming into this role, is to build a sustainable way to be more agile. And that might mean prioritising areas that need focus.

We've got 280-something guidelines across everything. And each of those guidelines has got tens, sometimes hundreds of recommendations. We can't look at everything all the time.

We're also keen to investigate the use of technology. For example, we are using, to some extent, artificial intelligence, keeping on top of the published literature base. You can program what search terms are, machine learning can learn what the routine is, so we're doing things to have a sustainable way to keep our guidelines current.

Involving Patients

Dr Chrisp: We have patients involved in the process.

Some people will end up on tens of medicines, which they may not want or need. And it's about their choice. And it's about shifting that culture so the patient preferences are a lot more prominent in the clinical discussion.

When we look at a new piece of evidence, and if we think 'no change', then we consult on that.

And people will come back and say, no, you've got that wrong, or we agree. And that will drive our decision about whether or not we update.

Patients are part of that consultation process.

Medscape UK: Is NICE prepared to change its mind?

It happens all the time. Science, medicine, is changing as we speak. It's not very black and white, clockwork, predictable. It's volatile, it's uncertain, it's complex, it's ambiguous.

Postcode Prescribing

Dr Chrisp told the conference how NICE was formed to help prevent postcode prescribing, where patients in different areas do or don’t have access to treatments or devices through the NHS.

However, he admits cases such as the FreeStyle Libre diabetes patch monitoring by smartphone system have shown that's not always the case.

Dr Chrisp: Sadly, not. What we don't know, of course, the counterfactual, what it would have been had NICE not been around. But we work closely with other programmes with colleagues across the NHS, the Getting It Right First Time Programme (GIRFT), for example, or Right Care, which looks at unwarranted variation.

So that's a really important topic. Because even things like prescribing antibiotics where you think it's pretty obvious that you wouldn't prescribe an antibiotic routinely for somebody with a sore throat, for example, there are still pockets where that happens. So it's a bit like, everybody knows, you shouldn't smoke but 10% of the population still do. So there's only so far you can go. And what we do with our field team, or medicines implementation associates, is we try to work with those local health economies to try to manage that down, and working with our colleagues and with the programmes across the NHS.

On this issue of postcode lottery, one thing NICE has done of course, is it has eradicated that in terms of access to medicines. And that's really important.

If NICE says that a medicine is recommended, it means that you as a patient in the NHS constitution have got the right to that medicine.

Whether or not CCGs (clinical commissioning groups) comply with that is a different question. If NICE says recommended, it should be an option for you, if that's what you and your clinician agree is the best course of action.

Medscape UK: Does that mean people may have to fund treatment themselves?

No. That should never be an outcome for something which NICE has said 'yes' to. Where NICE has said 'no', then in that instance they may need to pay themselves, because our job is to look at the cost effectiveness.

We've got a finite NHS budget. For every pound, there's an opportunity cost. If you spend it on one thing, you're taking it away from something else. And that's at the heart of what we do.

Mandating Funding

This week NHS England announced it would end postcode prescribing of FreeStyle Libre by mandating funding by the remaining CCGs. Does Dr Chrisp think we'll see more interventions like that in future?

Dr Chrisp: Possibly. It's good that it has, because the NICE guidance says it's a cost effective intervention. So that's good. We work closely with NHS England on their commission policies. So there's many levels of engagement between NICE and NHS England, and the Department of Health and Social Care.

There are two things here: cost effectiveness and affordability. So you might be in the market for a new car, and you might look at fuel efficiency, that's a measure of cost effectiveness. Now it might be the car costs £50,000, and you probably can't afford that.

We're having that debate sensibly now with NHS England. We'll say

our projections are that if we say yes, this number of patients would be eligible. It looks like it's going to cost this, therefore the projection is this is going to be the hit on the NHS budget.

Medscape UK: So are things like the Freestyle Libre mandate more likely to occur?

Dr Chrisp: Possibly, but it's about that dialogue, and it's about what NICE's role is to look at the evidence, and to say, yes that's a good use of taxpayers' money.

Medscape UK: Should CCGs be mandated to fund all NICE guidelines?

Dr Chrisp: No. I wouldn't be comfortable [with that] for a guideline.

You still need clinical judgment and patient choice. Good evidence-based medicine is that intersection between the evidence, the clinical judgment, and the patient preferences. Where those things intersect, that's evidence based medicine. It is not slavishly following the guideline.

The way medicine should be practised is, you talk to the patient, and you say which bits of NICE guidance should I have this conversation about? Not I'm going to wrap this guideline around this patient.

So to mandate guideline recommendations, no, I don't think so. Maybe with one exception, and it's how our evidence analysis can identify interventions which are of, maybe, lower value. And we work again, with colleagues at NHS England, and other stakeholders.

There was a consultation recently on the evidence based interventions programme, which was built on the foundation of NICE recommendations where we said, you shouldn't be doing that. Or, you should only do that in patients with such and such characteristics. Now, that's where we can give a kind of a signpost to commissioners to say if any of your CCGs or trusts are still doing this, maybe have a conversation because the evidence suggests it's not cost effective, or clinically effective.

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