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NICE Implementation Collaborative (NIC)
 

The NIC is a unique partnership between the NHS, Life Sciences industry, Healthcare professional bodies, key health organisations and Patient groups. NIC partners are committed to working together to support a system where patients have faster and more consistent access to NICE-recommended medicines, treatments and technologies and is a collaboration which completely re-draws the landscape. Industry will now work with academia, clinical groups, NHS England, NICE and representative bodies to drive compliance with NICE recommendations.

The partnership underpinned by the signing of a concordat in March 2013. The Concordat is made up of the following members:

  • Academy of Medical Royal Colleges
  • Association of British Healthcare Industries (ABHI)
  • Foundation Trust Network
  • NHS Alliance NHS
  • Commissioning Assembly
  • NHS Confederation
  • NHS England
  • National Institute for Health and Care Excellence (NICE)
  • Patients Involved in NICE
  • Royal Pharmaceutical Society
  • The Academy of Medical Sciences
  • The Association of the British Pharmaceutical Industry (ABPI)
  • The British In Vitro Diagnostics Association (BIVDA)

What does the NIC do?

  1. Identify practical measures that support and promote timely and consistent implementation of NICE Technology Appraisals throughout the NHS in England
  2. Work jointly to support and promote the adoption of all other forms of NICE guidance that apply to the NHS in England, and to drive the uptake of innovation, in a way that is consistent with local health needs and priorities
  3. Understand the barriers that restrict expected levels of implementation and uptake, including the requirement for CCGs to provide care for their populations taking into account local affordability and clinical need. The NIC will identify practical measures that its members and all organisations providing NHS services to patients can take to help overcome these barriers
  4. Support a culture shift within the NHS in favour of clinically- and cost-effective innovation

 

Small arrow Latest NIC work streams
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Nalmefene (NICETA 325)

NIC image Nalmefene (NICE TA 325) for reducing alcohol consumption in people with alcohol dependance.

The NIC currently has a work stream looking at the implementation and uptake of Nalmefene. The following page summarises the NIC work stream.
 

Background

In England, alcohol dependence affects approximately 4% of people aged 16-65 years. It is associated with an increased rate of significant mental and physical disorders (including cardiovascular disease, neurological disorders, gastrointestinal disorders and mental health disorders). However, treatment rates are low. Most specialist services aim to cater for people with moderate to severe dependence. Importantly, mild dependence represents by far the largest group of individuals. Most of these people present in a primary care setting with limited initial assessment or treatment for their dependence, and indeed poor service provision should referral for specialist treatment be offered.

Nalmefene (Selincro®) is an orally administered opioid receptor modulator which has a UK marketing authorisation for: ‘the reduction of alcohol consumption in adult patients with alcohol dependence who have a high drinking risk level, without physical withdrawal symptoms and who do not require immediate detoxification’.

The drug is taken on an ‘as needed’ basis, meaning it should be taken on those days when the patient has the urge to consume alcohol. It should also be prescribed alongside continuous psychosocial intervention. In phase III clinical trials, nalmefene alongside psychosocial intervention led to a 61% reduction in alcohol consumption, versus baseline.

Nalmefene represents a novel approach to the treatment of those with alcohol dependence. Whilst there may be novel elements of the pharmacology, the real innovation lies in the application of the technology. Nalmefene is the first drug licenced for the reduction of alcohol consumption (rather than abstinence) which is important given WHO data showing the benefits for a reduction in WHO drinking risk levels in terms of mortality. Furthermoreco-morbidity data (eg 16% of all hypertension is attributable to alcohol, indicates a strong dose relationship between increased alcohol intake and increased hypertension risk with similar data for other co-morbidities such as cancer, diabetes and depression. Nalmefene may also be prescribed by GPs which allows mild dependent patients to be treated in a setting most suited to their needs in line with NICE commissioning guidance for alcohol misuse services.
 
Barriers to adoption

Despite the high negative impact of alcohol on health and wider society, alcohol dependence is still poorly recognised and managed within the NHS, and primary care in particular. Nalmefene (if approved by NICE) would represent a cost-effective treatment option opening up treatment to a significant number of mildly dependent individuals who currently have very limited options at best or no access to treatment. Nonetheless several potential barriers exist:

  1. Interaction between public health / local authorities, and NHS England / General Practice. This STA is potentially the first guidance which will have an impact upon local authorities as well as CCGs. The Health & Social Care Act stipulates that the funding mandate for NICE technology guidance applies to local authorities as well as CCGs. However this is not widely known, and will have implications for budget planning. There is a risk that local authorities and CCGs will spend time trying to pass the accountability back and forth, rather than focussing on the implementation to the benefit of patients.
     
  2. Absence of established care pathways.Typically services today are poorly defined. GPs typically refer moderate and severe alcohol dependent patients to specialist services, which in themselves are variable in availability and design (frequently provided by third sector organisations such as Turning Point and the Crime Reduction Initiative without access to prescribing support in some cases).
     
  3. GP awareness and knowledge. GPs are aware of the burden of alcohol dependence, and readily accept the link to common co-morbidities. However there is a lack of knowledge leading to a clear reluctance towards diagnosing and managing this themselves:   The factors which appear to contribute to this issue are limited treatment options within a primary care setting, constrained time resources and a set of incentives which are considered too low value to prioritise over other therapeutic areas (e.g. no specific QOF indicator for alcohol screening and intervention and inclusion in Health Check & as a DES but currently with low uptake for both schemes)
     
  4. Understanding psychosocial intervention. The clinical studies for nalmefene involved the drug being used alongside psychosocial support called BRENDA. This was a low intensity psychosocial intervention (as required by the EMA for regulatory approval) with the aim of supporting a goal of reduction and treatment adherence. The licenced indication stipulates a similar psychosocial intervention be used in clinical practice. The current NICE guideline refers to use of psychosocial support, but of a higher intensity than BRENDA. Unless GPs understand the difference, there is a risk of the technology not being implemented. The type of support referenced in CG115 is not so widely available in a primary care setting. The provision of an intervention similar to BRENDA is very much more feasible and would be equivalent to existing interventions such as extended brief interventions or motivational interviewing.  There are also a number of online psychosocial support tools available.

Focus of the NIC work stream

The focus for the NIC work stream will be to support the implementation of this guidance within a primary care setting. The work will demonstrate that it can be done in a practically feasible manner, with meaningful and realisable health gains through reduced alcohol consumption and an improved co-morbidity profile.

 

Small arrow NIC CONTACT
Dr James Rose James.rose@oxfordahsn.org


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Other relevant initiatives 

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Road map link

Innovation Compass link