Following an independent review, the States of Guernsey formally adopted a policy of funding NICE technology appraisal recommended treatments in a phased way, with the most cost effective treatments introduced first.
In 2023, Arden & GEM’s Solutions for Public Health team was commissioned to evaluate the first two years of the implementation of the new policy. The evaluation process included data analysis, clinical engagement, desk research and stakeholder consultation.
A final report was presented to the Health and Social Care Committee and included a review of policy implementation, a future options appraisal, and recommendations to improve data collection and quality.
The challenge
The healthcare system for the States of Guernsey (a British Crown Dependency) is different to the NHS in England, with secondary care treatments funded by the States’ Committee for Health and Social Care and primary care remaining privately funded. Unlike the NHS, Guernsey is not mandated by law to make funding available for treatments recommended by National Institute of Health and Care Excellence (NICE) technology appraisal (TA) guidance.
In 2018, the States of Deliberation recommended that there should be an independent review to determine whether the States of Guernsey should routinely fund NICE TA guidance in order to improve patient outcomes and address the differing standards of care for patients treated on-island and those treated on the mainland.
Following a six-month review, completed by Solutions for Public Health (SPH), the States of Guernsey formally adopted a policy of funding NICE TA recommended treatments in a phased way, with the most cost effective treatments introduced first.
In 2023, the States of Guernsey commissioned the SPH team, through a competitive tender process, to evaluate the first two years of the implementation of the new policy with the following requirements:
- A review of the implementation of year 1 NICE TAs with of an Incremental Cost Effectiveness Ratio (ICER) value up to £30,000
- A review of the implementation of year 2 NICE TAs with an ICER value up to £40,000
- An appraisal of options for future implementation of NICE TAs
- An evaluation as to whether Guernsey and Alderney can participate in, or create its own, Cancer Drug Fund (CDF) and/or Innovative Medicines Fund (IMF), considering the health, economic and practical impact of this
- An evaluation of the future of the NICE TA system within the NHS.
Our approach
The SPH team worked with the Prescribing Support Unit on the islands to identify the NICE TAs funded during 2021 and 2022. Data on the number of patients treated and the prescribing costs of each drug was supplied by the Prescribing Support Unit.
Estimating future costs to inform policy
A range of activities was undertaken to generate potential policy options for consideration by the States of Guernsey.
- To help estimate future costs of continuing to fund NICE TAs, the SPH team estimated the annualised cost of treatment for each NICE TA.
- To help estimate the future number of patients for already funded NICE TAs, a proforma was circulated among medical consultants on the island asking them to estimate how many patients they might expect to qualify for each treatment under each TA. Follow up interviews were then conducted.
- For TAs funded in the first two years of the policy, but for whom no patients had so far required treatment, NICE estimates of expected patient numbers in England were used with British National Formulary prices to calculate likely future costs per patient. These were combined with the estimates of patient numbers.
- To assess non-prescribing costs, the SPH team conducted face to face interviews and attended existing forums with clinicians, service managers, pathology and finance staff.
Resulting policy options ranged from continuing to fund only those TAs which had so far been funded under the existing policy to funding all NICE approved TAs regardless of cost effectiveness. For each option we estimated the number of patients likely to receive treatment per annum and the likely cost of treatment.
Understanding the NICE TA forward programme
In terms of the future funding of non-drug TA interventions the SPH team sought to understand the extent to which the NICE TA publications and future work programme cover non-drug interventions and for which clinical specialties and also confirmed the extent of non-drug TA funding in the States of Guernsey.
Joining existing Funds
When considering whether the States of Guernsey could or should attempt to join the Cancer Drugs Fund and/or Medicines Innovation Fund, which operate on the mainland, the SPH team carried out desk research supplemented by informal conversations with senior stakeholders in NHS England.
Outcomes
The evaluation was completed by the agreed deadline and included all the requirements specified by the commissioner. The final report was presented to the Health and Social Care Committee by the SPH team.
The Committee favoured the suggestion for multidisciplinary prioritisation of NICE TAs using a service development model made in the evaluation report.
The evaluation identified 149 NICE TAs that had been approved in the two year period. Of these, prescribing data was available for 64 TAs. The total prescribing cost over the two years was in the region of £4.3 million and just under 900 patients had been treated with NICE TA approved drugs over the two year period. Around three quarters of these patients were treated for cancer, rheumatoid disease, cardiac disease or an eye condition called wet age-related macular degeneration. This represented a significant change in access to NICE recommended treatments for the population of the States of Guernsey.
The evaluation noted that the cancer specialty particularly stands out as needing systematic, planned, multi-service implementation of new drug therapies. This is particularly important given the preponderance of cancer drug therapies on the NICE TA forward programme.
The evaluation also recommended that the States of Guernsey consider adopting a cloud-based data management system such as Blueteq which is used widely throughout England and Wales for the approval and management of treatments across a wide range of indications. This both rationalises the existing data collection systems and improves the quality of available data around approvals and costs of treatment.
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