>>James Palmer: Hello I’m James Palmer, I’m a consultant neurosurgeon, but I also
work for NHS England as their Medical Director for Specialised Services. Every year as a
consultant neurosurgeon I see new treatments coming into my clinical practice, and across
the NHS as a whole there are many treatments that come across all of the specialties that
the NHS has to cover. Some of those are very expensive and need to be considered whether
they should be introduced or not. NHS England relies on a committee called the Clinical
Priorities Advisory Group, which looks across all of the new treatments coming for each
of the service areas, and they in turn make recommendations back to the NHS board on which
of those to select based upon their relative clinical benefit and their relative cost.
So how do the Clinical Priorities Advisory Group, or CPAG, do their work? Well we’ll
have to go into a little bit of theory first. Let’s plot an x axis which describes the
benefit and a y axis that describes the cost. Where they cross in the middle a treatment
if it were plotted here would have no benefit compared to current treatments, and the cost
would be no different to current treatments. So a treatment lying on the y axis going upwards
would be one of increasing cost, and a treatment on the y axis going downwards would be one
of decreasing cost. If you plot treatments on this graph in that way, in the top left
hand section are those treatments of more cost and less benefit. Those in the bottom
left are those with less benefit and less cost. Those in the bottom right are those
with more benefit and less cost. And those in the top right are those with more cost
and more benefit. So looking at each section in turn, let’s first look at that top left
hand box. These are the treatments that cost more but have less clinical benefit. We would
not want to introduce any of those into the NHS. If we look at the quadrant on the bottom
left, which is less cost and less benefit, we might want to introduce treatments in this
area but only if the benefit change was very marginal compared to current treatments, but
we would proceed with caution here. In the bottom right hand quadrant are those treatments
that are more benefit for less cost and we would definitely want to introduce those as
soon as possible to the NHS. Most of our new treatments though fall in the top right hand
quadrant. These are treatments that cost more but also provide more clinical benefit.
So how do we make decisions about treatments that fall in that top right hand category?
Those treatments that cost more but give more clinical benefit. Well we use a technique
called the Boston matrix and you divide that quadrant in that top right into nine additional
boxes, splitting the benefit into three categories; low benefit, medium benefit and high benefit
and splitting the cost into three categories; low cost, medium cost and high cost.
So let’s imagine that we’ve got twelve new treatments to consider for investment
in the coming year. What we do is ask the clinical priorities advisory group, called
CPAG, to take those twelve new treatments and look at their clinical benefit. At this
stage they have no idea of the cost of these treatments. They then split those twelve into
equal numbers through the three categories, four in the low category, four in the medium
category and four in the high category. That CPAG group is made up of doctors, nurses and
members of the public and they make those decisions through deliberative debate and
discussion and come to a consensus agreement. Now let’s look at the cost. Our finance
experts and analytical experts look at the cost of each of these twelve treatments over
the course of a five year period and then they are able to rank from the bottom to the
top, lowest cost to highest cost the treatments in order. Furthermore we then ask them to
split those treatments into an equal number of treatments within each of the three categories;
low cost, medium cost and high cost - ending up with four in each category. Bringing this
all together onto the matrix you can see this three by three nine box grid. Take a look
at that bottom right hand corner. Treatments that fall into this category will be those
of the highest clinical benefit and the lowest cost. Clearly this is the priority that the
NHS would want to introduce first.
Now look at the box in the top left. Treatments that fall into this category would be those
with the lowest clinical benefit but the highest cost. Clearly this would be the lowest priority
for introduction into the NHS. Looking across the whole matrix the Clinical
Priorities Advisory Group can recommend five levels of treatment priority. As a result,
the Clinical Priorities Advisory Group then makes its recommendation to NHS England and
its board. They have listed the 5 levels of relative
priority and identified the treatments that sit within each of those 5 levels. NHS England’s
board then knows how much money it has to be able spend on behalf of taxpayers in the
next financial year. And they can then decide how many of those levels of treatment they
can afford to commit to.
There might be enough money for them to commit to all of the five levels, but there might
be more limitation on resources so they might be only able to commit to four, three or two
of those levels. If some levels aren’t able to be committed to in the next financial year
there is always the opportunity for the treatments that lie in those levels to come back to the
next Clinical Priorities Advisory Group for a further review in six months’ time – and
these can be reconsidered up to three times.
We in NHS England have a duty to look at all the new proposals for investment and make
sure that their based on convincing and sound evidence of clinical effective and safety.
Furthermore, we need to make that our decisions are affordable and the process we have undertaken
is fair and transparent. This process allows us to identify the drugs, treatments and interventions
which are the best use of resources and provid e the maximum benefits for patients.