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EDITORIALS: Gary L Davis Treatment of chronic hepatitis C BMJ 2001; 323: 1141-1142 [Full text]

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Not so, NICE

William Rosenberg   (22 November 2001)

Not so, NICE 22 November 2001
William Rosenberg, Senior Lecturer in Medicine, University of Southampton Southampton General Hospital, Tremona Road, Southampton, SO16 6YD Send response to journal: Re: Not so, NICE	Sir, The British Medical Journal has recognised the considerable advances in the treatment of Hepatitis C . Estimates of the scale of Hepatitis C virus (HCV) infection in the UK suggest that 0.4% of the population are infected but this may be an underestimate as it is based on antenatal clinic testing . Effective treatments described by Gow and Mutimer have raised the hopes of patients and their doctors alike. In their review drew attention to the favourable guidance (www.nice.org.uk Guidance Number 14) issued by the National Institute for Clinical Excellence (NICE) which advocates the widespread use of Inteferon alpha and Ribavirin in combination for all eligible patients. Despite this positive guidance access to treatment remains subject to “post-code” prescribing, with marked inequality in the funding of treatment across the UK. In a survey of 13 established centres treating patients with HCV only 2 have funding available for the treatment of all eligible patients. The 13 centres have subtract 282 patients awaiting treatment and funding is available for only subtract 99. In almost all cases the funding will cover drug costs alone and not other services that influence the quality of care available to patients with HCV. Seven centres reported difficulty in funding diagnostic tests. Four centres have no funding for a NHS nurse while 4 await further negotiations before appointments can be made. Although the NICE guidance drew attention to the need for appropriate services for diagnosis and the delivery of treatment, sufficient funds may not be forthcoming as the budget for implementing Guidance 14 is based on an underestimate of prevalence and patterns of referral appropriate to interferon monotherapy. Furthermore the full costs of investigation and management using the more effective combination therapies were not considered. The Guidance is not due for review until 2003. There is little incentive for Health Authorities to implement NICE guidance for technologies outside the National Service Frameworks and none to fund comprehensive services as well as the drug budget. Furthermore their estimate of prevalence appears to be inaccurate. As a result of the continuing under-funding of HCV services, patients are likely to remain the subject of regional inequalities in the provision of healthcare. Failure to spend appropriate sums of money on treatment now will result in far greater healthcare costs in the future, when untreated patients develop end-stage liver disease . Given the size of the problem a national strategy for Hepatitis C, possibly as part of a National Service Framework for hepatology, might be the only way to ensure a more adequate, even and appropriate distribution of funds and services for this important disease. References Davis GL. Treatment of chronic hepatitis C. BMJ 2001; 323:1141-2. Unlinked Anonymous Surveys Steering Group. Prevalence of HIV and hepatitis infections in the United Kingdom in 1999. London: Department of Health, Public Health Laboratory Service, Institutes of Child Health (London), Scottish Centre for Infection and Environmental Health. 2000. Rosenberg WM. Screening and shouting about HCV. Gut 2000; 47(2): 165- 6 Gow PJ and Mutimer D. Treatment of Chronic Hepatitis. BMJ 2000;323:1164-7 Wong JB, McQuillan GM, McHutchison JG, Poynard T. Estimating Future Hepatitis C Morbidity and Mortality in the United States. Am J Public Health 2000;90:1562-9. Author: William Rosenberg, Mailpoint 811, Level D South Block, Southampton General Hospital, Tremona Road, Southampton SO16 6YD; Contributors: Graeme Alexander, Addenbrooke’s Hospital, Cambridge; Alison Brind, Stoke on Trent; Matthew Cramp, Derriford Hospital, Plymouth; Jane Collier, John Radcliffe Hospital, Oxford; Graham Foster, St. Mary’s Hospital, London; Charles Milson, St. James’ Hospital, Leeds; David Mutimer, Queen Elizabeth Hospital, Birmingham; John Ramage, Basingstoke; Steve Ryder, Queen’s Medical Centre, Nottingham; and Thomas Warnes, Manchester.