During the one session on value based assessment (VBA), the audience heard from 3 speakers:

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2 The chair of NICE, David Haslam, initiated the conference by focussing on the importance of NICE and other health technology assessment (HTA) bodies in terms of the need for technology appraisal in a world where there is a finite healthcare budget. He emphasised that NICE has made 514 individual recommendations to date, 80% of which were positive. He also commented on the need for a better understanding of the true cost of drug development, in order to help evaluate the need for the high drug prices that are increasingly being seen. Following this introductory focus on technology appraisal, however, very little of the rest of the conference touched upon this role of NICE. Outlined below are some of the sessions that were most relevant from a pharmaceutical industry perspective. During the one session on value based assessment (VBA), the audience heard from 3 speakers:, Programme Director of Technology Appraisals at NICE, reiterated the concepts of VBA as set out in the NICE consultation paper, namely burden of illness (BoI) being represented by the proportional QALY shortfall and the wider societal impact (WSI) being represented by the absolute QALY shortfall. He acknowledged that the absolute QALY shortfall did have an age-biased component, as younger people have the potential to impact to a greater extent on society over their remaining lifespan. It was also clarified that the BoI and WSI were not related to the impact of the new technology, but assessed the condition as it is currently being treated without the new technology. Disappointingly, no further technical details on VBA were given. NICE Annual Conference 2014 Copyright Costello Medical Consulting Ltd 2

3 , Chief Executive of the Association of the British Pharmaceutical Industry (ABPI) gave the industry perspective on NICE s VBA consultation paper. He praised NICE for their pragmatic and sensible approach to VBA. However, he stated that he could not see how VBA will allow greater access to new technologies, as the cost of developing drugs is increasing and the targeted nature of drugs to smaller, more specific patient populations means that drug prices will need to remain high., from Genetic Alliance UK, spoke from the patient perspective. He was keen to understand how VBA will work for rare and orphan indications, where ICERs will continue to come well above the 50,000 threshold, and how the QALY-based method of assessing BoI and WSI will take into account aspects of the condition important to patients that may not be fully captured by the QALY. He called for a higher level of patient engagement in developing VBA. The session on developing a value proposition for technology appraisals called for greater engagement between industry partners and NICE. NICE want industry to understand the methods of technology assessment and want to encourage robust data generation. One speaker presented the Scientific Advice Service, where NICE provide fee-for-service, but not-for-profit, advice to manufacturers on how to develop and present the most favourable evidence base for their technology. The importance of considering HTA at an early stage of drug development and designing clinical trials with the endpoints required for a successful HTA decision in mind was discussed. The need for innovation to facilitate the delivery of new technologies and the dissemination of new ideas across the NHS was the topic of a panel discussion consisting of representatives from the ABPI, the Association of British Healthcare Industries (ABHI), Academic Health Science Networks (AHSNs) and NHS England, who noted that partnership working between the NHS and industry has not been systematic up to this point. This session discussed a number of examples of initiatives that aim to increase the level to which industry and the NHS operate as partners: Carol Blount from the ABPI highlighted the innovative new Pharmaceutical Price Regulation Scheme (PPRS) scheme as a new way of working between industry and the NHS. The main focus of the session were the AHSNs, which have been introduced to work with industry and help generate a step-change in the way the NHS identifies, develops and adopts innovative new technologies, in order to drive health and wealth improvements for the public. Melanie Ogden of NHS England pointed to innovation scorecards, which have been introduced as a way to measure the innovative nature of each NHS Trust, in order to allow comparison and to create a quality standard for adoption of new technologies. Overall, the discussions on increased partnership working were relatively broad and it seemed to be too early to give practical examples or case studies of how these mechanisms for facilitating innovation will work in practice. NICE Annual Conference 2014 Copyright Costello Medical Consulting Ltd 3

4 The key buzz word of the conference was integration, which was described by the David Haslam as the flavour of the month. It was also recognised that the same language around integrating primary, secondary and social care, as well as public health, has been used for the last decade. However, there were many speakers who emphasised the real changes that are now being made towards creating a joined up approach to healthcare. NICE are playing a key role in the move towards real integration, with their evidence-based guidance covering all areas of healthcare, public health and social care (see below). However, the largest barrier to providing integrated care, as voted by the conference audience, was the different funding systems for each element of health and social care. The responsibility for public health now sits within local councils, and the Chief Operating Officer of Gloucestershire County Council pointed to the importance of considering how this may affect the way in which public health interventions should be communicated. Since local councils are elected bodies, and voters typically think of councils in relation to pot holes and bins, public health agendas need to be matched to council agendas to gain buy-in from council leaders, who may have very different incentives and be much less familiar with public health terminology to those previously responsible for public health. The panel highlighted the need for rapid diagnosis to give prescribers the confidence to delay antimicrobial use where possible in order to limit the emergence of anti-microbial resistance. Despite NICE guidance to delay or give no prescription for uncomplicated symptoms, many practitioners have not successfully reduced their prescribing. However, the winner of the shared learning awards 2014 had reduced unnecessary prescribing of anti-microbial drugs by 15% in primary care using an easily reproducible approach based around patient education on typical symptom duration. Currently, the NHS Breast Screening Programme offers mammogram screening to women aged 50 to 70; however a recent review concluded that although this public health intervention saves lives, screening results in considerable over-diagnosis. Many genetic determinants of breast cancer risk are known, which allows us to identify those at high and low risk. Dr James Flanagan of Imperial College London raised an interesting question in this context: now that we can identify those at high risk using genetic markers, and therefore also identify those at much lower risk, should we stop screening in the low risk population? NICE Annual Conference 2014 Copyright Costello Medical Consulting Ltd 4

5 Patient-centred care was a key theme at the conference, following the publication of two seminal reports, the Berwick report and the Keogh report, which claim that informed and engaged patients are essential and call for patient involvement in the Care Quality Commission, respectively. 1, 2 It is becoming increasingly obvious that the patient experience can tell us a great deal about both the outcomes of treatment but also the quality of the care that patients have received. It will also become increasingly easy to involve patients in their own care, with the advent and distribution of more and more new digital technologies to collect patient data and to inform patients. It was also highlighted that in addition to the patient, the experience of the relatives and also of the staff providing the care are very valuable too. There is currently a lack of evidence on whether involving patients more in their own care actually has any impact on patient outcomes and whether it is a cost-effective initiative. 3, 4 Although patient-centred care has become a frequently used term, it was actually challenged by one of the speakers, who argued that patients should not be placed in the centre with people talking about them, but they should be at the table, as part of the discussion. In another session, the title the informed patient was also challenged, as it was stated that equally important to teaching the patient about their condition is to listen to the patient's thoughts on the most important elements of their condition. Collection of data about patient experience in real time is apparently now conducted in all hospitals, according to Neil Churchill from NHS England. The issue now is ensuring sufficient resource to permit analysis of this data so that it can be used most wisely to inform and change practice. There are new initiatives such as the independent website iwantgreatcare, which are collecting patient views and ratings of different service providers; there was some debate over whether these would actually change the quality of care, but it was suggested that making providers sign up to such a site could become a contractual part of commissioning. There was a call for NICE to create a quality standard for patient information, to ensure that data is communicated and terms are explained to patients in the most useful way. It was also asked of NICE to create patient decision aids that allow patients to make their own decisions about their care rather than plain language summaries which simply explain to a patient what will happen to them. NICE are planning to pilot two such decision aids in the near future. NICE Annual Conference 2014 Copyright Costello Medical Consulting Ltd 5

6 One stream of focus at the conference was on NICE guidance and best practice, which included sessions on updates to the NICE approach to guidelines and implications of this for their uptake, as well as the introduction of a new type of guideline on NHS staffing. Following the report of the Francis enquiry, NICE will now publish guidelines on safe staffing capacity and capability within the NHS. The first guideline, on safe nurse staffing for adult hospital wards, is expected in July NICE guidelines will now become an umbrella term for all guideline types. NICE plan to integrate the current different forms of guideline into a single comprehensive guideline on each topic, with the aim of this being to increase uptake, enhance flexibility in guideline development, allow for greater consistency in stakeholder involvement and, importantly, to fit with the theme of increasing integration of the clinical care, social care and public health activities of NICE and the NHS. A unified manual detailing a proposition for how to achieve this integration is currently out for consultation ( and it was noted that in particular there will be considerable thought given to how relevant points can be effectively targeted at the appropriate reader within these new, larger guidelines documents. 1 Berwick D, The National Advisory Group on the Safety of Patients in England. Improving the safety of patients in England: A promise to learn - a commitment to act. August Keogh B. Review into the quality of care and treatment provided by 14 hospital trusts in England: overview report. July Stacey D, Legare F, Col NF, et al. Decision aids for people facing health treatment or screening decisions. Cochrane Database Syst Rev 2014;1:CD Walsh T, Barr PJ, Thompson R, et al. Undetermined impact of patient decision support interventions on healthcare costs and savings: systematic review. BMJ 2014;348:g188. NICE Annual Conference 2014 Copyright Costello Medical Consulting Ltd 6