1. Assessment and Appraisal: Fundamental Aspects of Health Care Kent Woods Director, NHS Health Technology Assessment Programme

2. Key themes in health care The accelerating pace of health technology The interplay of science and judgement at all levels of health care The need for rigour in decision-making

3. Diagnostic technologies Radio immunoassay Flexible endoscopy Computerised tomography Diagnostic ultrasound Therapeutic technologies 1,106 new drugs marketed 1970-92 New devices (pacemakers, stents…..) New surgical procedures (transplantation, laparoscopy…)

4. Drugs

5. 4S CARE WOSCOPS (statins £308m)

6. Percutaneous coronary intervention Coronary artery bypass grafting

7. What is HTA for? To supply the evidence base for those who plan, manage, provide or use health services in making decisions HTA does not make or determine the decisions HTA is needed at every level of health care

8. Assessment is a research activity and produces generalisable new knowledge ‘Appraisal’ applies that knowledge to specific local circumstances: –Applicability –Social values –Local priorities –Local resources Responding to the challenge of new technologies

9. Clarity (and accountability) of function Application of the right skills and competencies Assessments are transferable and replicable Why Separate Assessment and Appraisal?

10. HTA Programme NICE National Screening Committee NSCAG National: [Local commissioning] [Clinician/patient] AssessmentAppraisal

12. A methodology of appraisal The principles underlying decision-making have received less rigorous attention than the science, e.g: Equity? Priority? Efficiency? Individual preference/societal values?

13. HTA in Support of Appraisal NICE –40-50 TARs per year NSC –Systematic reviews on screening for prostate cancer, Down’s, HPV in cervical screening –RCTs on same topics NSCAG –ECMO trial; ventricular assist devices

14. 1.Science informs, but does not dictate, decisions in health care 2.The scientific challenges are: –Synthesising evidence validly –Quantifying uncertainty –Communicating probabilities to those making decisions

17. Future issues for better decision-making Assessment –Synthesis from diverse study designs –Preserving transparency –Growing the research capacity Appraisal –Adapting to rapidly moving evidence –Developing and ‘selling’ explicit principles –Locating decisions at the right level