by Natalie Morrison

LONDON, 27 July (APM) - “Simplifying and streamlining” assessment work will be a goal for NICE, including potentially re-imagining the shape of its committee stage in technology assessment, the health assessor’s newest head of technology evaluation Meindert Boysen told APM.

Boysen took over the role from Professor Carole Longson earlier this year after she spent 17 years in the position (APMMA 56594, APMMA 57974).

Speaking with APM earlier this week for the first time in his new role, Boysen said he believes that NICE needs to make changes that are focused on simplifying and streamlining work.

He said one of his priorities over the next year is to think about the fact NICE has been running seven committees as part of its technology appraisals process, and “whether that is the operating model that we can sustain”.

Drugs, devices and diagnostics going through single technology appraisal (STA) process in a bid to gain NICE’s recommendation for use on England’s NHS are assessed in detail by one of the seven appraisal committees, which are made up of 25 members including healthcare professionals, patients, technical experts and lay people. They judge the evidence provided and make decisions towards whether the drug is reimbursed. Of the seven committees, five are for drugs and some devices, and two are for devices and diagnostics.

“Are we able, with that group of committees, to continue making the difference people want you to make?” Boysen asked. “I go into that with an open mind,” he said, adding “I am absolutely saying there is a role for independent committees, that’s how we make a difference at NICE, we are running a model of engagement in which an independent advisory committee is central.

“My question is, do you need seven? Or can you [have], like in other countries, where most countries have only one appraisal committee? They don’t have seven.”

He said the question is whether NICE can think about organising committees in a “slightly more efficient way”, but stressed their importance in considering the social value judgement inherent in the process.

“It’s not just about calculating a number and saying ‘yes or no’. It’s about listening to what patients currently have, what physicians think the technology might bring and making a decision based on what is in front of them and based on prior beliefs on what is right and wrong,” he said.

“Definitely there will always be, in my mind, an independent advisory committee of some kind,” he added. “But it is really difficult to imagine we now have to find on an almost bi-annual basis about 150 new committee members, with seven committees of 25 people each.

“The time we ask clinicians to spend with them and NICE is very valuable for frontline services too. There is a completely reasonable question to ask whether the amount of committee time we use for individual topics is the right amount, but the committee involvement is central.”

Technical engagement step

Boysen said this is also a reason to internalise the consideration of technical aspects “as much as we can” and highlighted the recent introduction of the technical engagement step prior to committee stage.

The step aims to iron-out a lot of the in-depth technical analysis before reaching the committee (APMMA 58694). It gives companies a chance to react by changing their value proposition, or by adding new evidence.

Speaking at NICE’s annual conference in Manchester last month, NICE’s associate director of the centre for health technology evaluation Jennifer Prescott stressed that NICE is not trying to reduce the committee’s decision-making power; rather it is trying to solve some of the uncertainties prior to committee stage to “course correct”, to “help the company create a much better value proposition and share their vision of what the value proposition is going to be” and clarify data before it is “too late” in the process.

Boysen echoed these comments, noting the added step is about “using our resources as efficiently as we can”, using NICE’s “highly skilled team” earlier in the process to relieve the committee of some of the work.

“I don’t think that’s taking away from what the committee might do”, he said, but added currently NICE spends five or so committee meetings resolving questions and issues for each assessment. He said the technical engagement step makes it easier for committees to have an important say on the key issues, rather than having to consider “every single issue as it comes”.

Only one programme has so far entered into NICE’s new STA process with the technical engagement step - Ipsen’s Cabometyx (cabozantinib) for the treatment of advanced hepatocellular carcinoma after prior therapy.

Boysen told APM another is soon to be implemented into the system - a type 2 diabetes drug.

Combining drug and med tech assessments

As for other streamlining efforts, Boysen also noted that NICE has a lot of activities targeted at pharmaceuticals, device, diagnostics and some digital which are currently all separate that could be more integrated.

He noted that in 2009, when NICE started med tech and diagnostics programmes, there was a sense that the evidence used to support marketing of these products was “very different” to what was classically seen for pharmaceuticals.

The value proposition made for med tech and medical devices was often one which proved equal or similar benefit and lowered cost, he said. Pharmaceuticals, on the other hand, typically went for improved effects at a greater cost.

However, some pharmaceutical value propositions are now becoming more similar to models seen in the med tech and devices world, he said, noting an “ever decreasing evidence base” with products getting licensed at an earlier stage in their life cycle, a “real importance for evidence collection and management” for these products once on the market and an appetite for cost minimisation.

Some of the value propositions for drugs are becoming more similar to what NICE would typically consider in the med tech realm, he said, with some medicine makers aiming to prove similar benefits for lower costs.

“By us broadening the number of pharmaceuticals we look at there is an appetite within industry and [within NICE] to simplify our approach from a very heavy handed cost utility analysis to something much more targeted proposition where the company [is saying] ‘we’re about the same price or less expensive and provide more or less same benefits’,” he said.

Boysen conceded there are currently not a huge amount of these cases, but noted NICE believes there is the ability within the technology appraisals programme to look at these drugs in a similar light to med tech and devices. There is “no reason to keep those separate”, he said.

nm/tm