5. Memorandum from Roche Products Limited
As the manufacturer of the treatments rituximab
and tocilizumab for people with rheumatoid arthritis (RA), Roche
Products Ltd welcomes the Public Accounts Committee's investigation
into services for people with RA. The National Audit Office (NAO)'s
report into services for people with RA has made clear that, "there
are opportunities to increase efficiency by addressing the delays
in obtaining formal diagnosis and treatment for many people with
RA".[47]
Following the oral evidence session of 23 November
2009, there are a number of points to which Roche would like to
draw the Committee's attention as it finalises its report. These
focus on economy (the minimising of costs of resources used for
an activity, having regard to appropriate quality), and efficiency
(the relationship between the output in terms of goods, services
or other results and the resources used to produce them).
First, with respect to efficiency, Roche would
like to highlight the information in the Department of Health's
programme budgeting data, and in particular the increase in expenditure
on musculoskeletal conditions. Although the musculoskeletal conditions
category does not capture expenditure on RA explicitly, it shows
that net NHS expenditure on musculoskeletal conditions more generally
has increased from £3,531,277,000 in 2006-07 to £4,085,030,000
in 2007-08 (an increase of almost 16%).[48]
It is difficult to quantify whether this increase in spending
has witnessed concomitant improvements in outcomes for patients,
since there is a lack of nationally-validated outcome measures.[49]
In order to measure the efficiency of RA services, this gap needs
to be addressed.
Second, with respect to economy, Roche would
like to draw the Committee's attention to the potential efficiencies
which could be made if the mandatory technology appraisal issued
by the National Institute for Health and Clinical Excellence (NICE)
in relation to rituximab was fully implemented by the NHS. NICE's
guidance on rituximab, published in August 2007, states that:[50]
"Rituximab, when given together with
methotrexate (another drug used to treat rheumatoid arthritis),
is recommended as a possible treatment for adults with severe
active rheumatoid arthritis only if:
— the person has already tried drugs known
as disease-modifying anti-rheumatic drugs to treat their rheumatoid
arthritis, one of which must have been an `anti-TNF' drug, but
these haven't worked or weren't suitable,
— it clearly improves the person's condition,
and doesn't need to be given more often than every six months,
and
— treatment is supervised by an experienced
doctor who specialises in rheumatoid arthritis."
The essence of the guidance is that rituximab
should be given to patients who have had an inadequate response
to an "anti-TNF" treatment. Given that rituximab is
39% less costly than an anti-TNF treatment (the cost of rituximab
per average patient per year is £6,127.68, compared to the
cost of an anti-TNF per average patient per year of £10,086.45,
inclusive of drug, outpatient, tariff and community costs), the
full implementation of NICE guidance has the potential to deliver
both savings to NHS organisations and improved outcomes for patients.
The NAO's report and the findings it contains allows, for the
first time, a national calculation to be made of the potential
efficiencies which could be realised:
— The NAO's report estimates that there
are 17,419 people with RA being treated with a biologic (either
an anti-TNF or rituximab) in England every year. 51
— Of these, it is estimated that 36.7%
are patients who have had an inadequate response to one anti-TNF
and are being treated with subsequent biologic therapies (ie 6,393
patients). 52
— However, Hospital Episodes Statistics
data suggest that only 1,759 of these patients are being treated
with rituximab across the country. 53
— This leaves an estimated 4,634 patients
who have had an inadequate response a first anti-TNF, but are
still being treated with them, even though if NICE guidance was
being correctly implemented then they should be being treated
with rituximab.
— At an average cost difference of £3,958.77
between the two treatments, the potential savings across the country
could total £18,344,175 per year, if the 4,634 patients were
being treated in line with NICE guidance.
Roche considers these savings additional to
the potential savings identified by the NAO in its report, which
focus on increasing the number of people diagnosed within three
months of onset of disease. 54
The remit of the Public Accounts Committee focuses
only on value-for-money criteria. However, a number of reports
undertaken this year—for example by the Rheumatology Futures
Group, and ARMA, in addition to the NAO—suggest that expenditure
on RA services and musculoskeletal services more broadly is inefficient
because services are inappropriately configured, and that this
is itself a manifestation of a lack of national clinical leadership
in government. In other areas, national clinical leadership has
demonstrated the ability to drive efficiencies in the spending
of public money, and has facilitated service change through the
provision of appropriate commissioning guidance and performance-management
measures. Although the appointment of a National Clinical Director
in musculoskeletal services is a policy solution, it has value-for-money
implications—given the National Audit Office's finding that,
"productivity gains could be achieved and patient quality
of life improved through better integration and coordination of
services, leading to quicker diagnosis and earlier treatment"—which
the Committee may wish to consider in its report. 55
November 2009
51 Based on the NAO-estimated cost of biologic
treatment of £160 million (page 8, NAO, Services for people
with rheumatoid arthritis, July 2009), divided by an average cost
of a biologic of £9,185.33. Roche data on file MabRA061.
52 GfK Study Quarter 3 2008: % of Total Biologic
Patients Receiving 2nd + line treatment.
53 Hospital Episode Statistics MAT August 2008.
MabThera patients estimated based on analysis of RA ICD-10 primary
diagnosis codes and rituximab OPCS-4 code.
54 P 9 NAO, Services for people with rheumatoid
arthritis, 15 July 2009.
55 P 8 NAO, Services for people with rheumatoid
arthritis, 15 July 2009.
47 P 9 NAO, Services for people with rheumatoid arthritis,
15 July 2009. Back
48
Department of Health, Programme budgeting data 2007-08, 16 July
2009. Back
49
ARMA, Joint working?, July 2009. Back
50
NICE, Rheumatoid arthritis (refractory)-rituximab, August 2007. Back
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