The first report by the National Institute for Health and Care Excellence (NICE) in March 2000, ‘Guidance on the Extraction of Wisdom Teeth’, seems innocuous enough, but it was not long before the UK health technology assessment (HTA) body – and the movement it spawned – was being blamed for blocking patient access to drugs and stifling innovation in the pharmaceutical industry.

“HTA is perceived as hurdle. But I struggle with that, because what HTA is doing is answering the most important question for health care systems and patients, which is not whether a product met its primary endpoint, but whether it will be clinically effective compared to alternatives,” says Professor Sarah Garner, Associate Director for Science Policy and Research at NICE.

Professor Garner’s view draws on an academic research project in which she interviewed stakeholders ranging from venture capital investors to physicians and patients. “This reinforced for me that HTA was not responsible for the industry’s productivity issues,” she says. “The fact is that HTA is the last in a long chain of events and because it works transparently, ends up taking the flak.”

The research pointed to a need to conduct a systematic assessment to uncover where the fundamental shortcomings lie. “You can fiddle with HTA methodology, cost thresholds, and so on, but this would not solve the problem – that the drugs coming through have not got the evidence they need and that the increases in costs are unsustainable.”

Based on this analysis, it is important for NICE to be part of the solution. “We should be working with all stakeholders to address these issues and make sure that the incentives are in place to find solutions in areas of high unmet need,” Professor Garner says.

Of course, NICE was not alone in recognising a different approach was required, and various projects and pilots are in train to develop new methodologies and tools, under the Medicines Adaptive Pathways to Patients (MAPPs) banner.

NICE is involved in a number of these initiatives, including the European Medicines Agency’s (EMA) Adaptive Pathways pilot, the Innovative Medicines Initiative (IMI) GetReal project and the Massachusetts Institute of Technology’s New Drug Development Paradigms (NEWDIGS) programme.

Pathway engineering

The aim of the EMA’s Adaptive Pathways pilot is to engineer a switch from the traditional approach of staging large and expensive phase III trials and granting approval in broad patient groups, to granting early approvals in areas of high unmet need and allowing the label to be expanded in line with the evidence.

The EMA cites several imperatives. In addition to patient demand for access and the fact that constrained budgets call for targeted drugs with increased therapeutic value, the Agency notes that segmentation is happening in any case, as a result of increased understanding of disease biology and the identification of subgroups of patients.

To help companies plot adaptive pathways, the EMA has held safe harbour discussions in which sponsors are able to have without-prejudice exchanges with regulatory and HTA experts, of whom Professor Garner is one. “I think this has proved very useful and there have been some fascinating discussions. It is helpful for small companies that have not considered the need for real world evidence or where a drug would fit into a care pathway and the value proposition of their product,” she notes.

Although the EMA has announced that nine products have been accepted into the Adaptive Pathways pilot, other details remain confidential for now. However, Professor Garner believes the pilot is prompting a more thoughtful approach at an early stage in development when it can make a real difference. This includes suggestions of new reimbursement models and more pragmatic trial designs. “For example, proposed trials are more ‘real world’ in terms of inclusion/exclusion criteria, and there is a blurring of phase III and phase IV,” she says.

“If you put