Health CommitteeWritten evidence from MSD-UK Ltd (LTC 24)

At MSD-UK, we believe the most important thing we make is a difference.

We operate in more than 140 countries and through our prescription medicines, vaccines, biologic therapies, and consumer care and animal health products we work with customers to bring innovative healthcare solutions to those who need them the most. We also demonstrate our commitment to increasing access to healthcare through far-reaching policies, programmes and partnerships.

MSD is a trade name of Merck & Co., Inc., with headquarters in Whitehouse Station, N.J., U.S.A. MSD has been based in the UK for more than 80 years:

We are a significant provider to the NHS.

We invest many millions of pounds in our UK facilities, including our laboratories in Hoddesdon which are a world-wide centre of excellence in chemistry.

The UK is also home to one of MSD’s most important manufacturing facilities outside of the US, producing tablets for worldwide markets.

We have the largest veterinary production facility in the UK.

We employ more than 2,000 people across four UK sites.

Executive Summary

Despite improvement in the last decade, more can be done to manage long-term conditions in the UK, for example UK lags behind European counterparts in improving CVD mortality rates.

Inequalities and variation in long-term condition mortality rates & access to care remain across the UK.

Proactively addressing long-term condition risk factors more robustly in the community-setting, such as for Cardiovascular Disease and Type 2 diabetes, has the potential to deliver a more “effective” NHS service (eg EiP Greenwich case-study). This should be driven through measures that encourage quality and can deliver overall cost-efficiency in the NHS, rather than short-term cost-savings with potential unintended consequences.

It is critical that we align how we measure and incentivise health-care professionals (& NHS England bodies) with national clinical guidelines on long-term condition risk factor management in order to address mortality rates, quality of life and costly complications.

Quality measures need to go beyond “testing” alone to ensure long-term conditions and risk factors are being effectively addressed nationwide and to further narrow inequalities.

With the creation of NHS England and the removal of certain information & education structures (eg NHS diabetes) it is key that new support structures are adopted rapidly in order to offer practical assistance to commissioners.

There are a number of examples of effective integration of services across health, social care and other services which treat and manage long-term conditions (eg First Diabetes (Derbyshire), EiP Greenwich case-study).

With an increasing ageing population it is key that more is done to address disease management of long-term conditions in the community-setting in order to improve mortality rates, quality of life and prevent costly hospital admissions and care. This should be supported by appropriate measurement and outcome indicators that are focussed on long-term savings not solely short-term savings.

We welcome the Health Select Committee’s inquiry into the Management of Long-Term Conditions. The points we would like to raise are as follows:

1. Despite improvement in the last decade, more can be done to manage long-term conditions in the UK, for example UK lags behind European counterparts in improving CVD mortality rates

1.1 Although significant improvements in the prevention and treatment of CVD over the last decade have been made, CVD remains one of the largest causes of death and disability in the UK.1

1.2 The Global Burden of Disease Study demonstrates that UK could do better in improving CVD mortality rates in comparison with other European countries.2

1.3 It is estimated that that there are approximately 2.5 million people diagnosed with Type 2 diabetes and up to 850,000 undiagnosed in the UK.119

1.4 The recent DUK State of the Nation report highlights that only half of people with Type 2 diabetes get the annual tests and investigations that are recommended in the national standards. Importantly, even where testing is taking place, many patients are not achieving the recommended target range for risk factors. More must be done to address this.3

2. Inequalities and variation in mortality rates & access to care remain across the UK

2.1 A wide variation in the treatment and management of diabetes across England remains.4

2.2 There are geographical inequalities across the UK in CHD mortality and this is often worse in areas of highest deprivation5

2.3 Another example of a national health inequality exists in the diagnosis and management of Familial Hypercholesterolaemia (FH) or “inherited high cholesterol” across the devolved nations.6

2.4 The recent NHS Information Centre on the “Use of NICE appraised medicines in the NHS in England 2010 and 2011, Experimental Statistics” showed that there was a variation in utilisation of medicines for long-term conditions. For example, the ratio of observed to expected usage of a NICE-approved non-statin cholesterol management therapy in the London SHA was approximately 0.6 in 2010 and 0.55 in 2011 versus nearly 0.9 in 2010 and nearly 0.8 in 2011 in the South East Coast SHA.7

2.5 Access restrictions to NICE approved medicines remains a problem at local formulary level, which can lead to postcode prescribing which reinforces healthcare inequalities.8

3. Proactively addressing long-term condition risk factors more robustly in the community-setting, such as for Cardiovascular Disease and Type 2 diabetes, has the potential to deliver a more “effective” NHS service. This should be driven through measures that encourage quality and can deliver overall cost-efficiency in the NHS, rather than short-term cost-savings with potential unintended consequences

3.1 NHS spending on diabetes was almost £10 billion in 2011, which was 10% of the NHS budget. 80% of NHS spending on diabetes goes into managing avoidable complications. People with diabetes account for around 19% of hospital inpatients at any one time, and have a three day longer stay on average than people without diabetes. Most of type 2 diabetes costs are due to hospitalisation.119

3.2 More effective risk factor management in the community has the potential to reduce costs to the NHS, while improving quality of care.

3.2.1Evidence into Practice (EiP) is a clinical change management programme. The programme aims to ensure that people with diabetes and those at increased cardio-metabolic risk receive optimal care through the effective implementation of national policy and guidelines, particularly NICE Type 2 Diabetes Guidelines. An example of the success of this approach was demonstrated in Greenwich. Results after one year showed that in practices who took up the programme a significant improvement in patients achieving NICE-recommended risk factor targets were achieved and substantial overall cost-savings were demonstrated due to a reduction in hospital admission rates. NICE have endorsed EiP as a proven case study for QIPP. NICE concluded that the programme scored 100% for evidence of change and 75% for both savings made and quality. This approach enabled the delivery of higher standards of care at a lower overall cost to the NHS.9

3.3 However, current national QIPP10 standards often focus on short-term drug budget savings through prescribing indicators rather than encouraging optimising medicines in line with NICE quality standards, guidelines and recommendations.

3.3.1For example, although the NICE Type 2 Diabetes guideline (CG87)11 outlines a number of treatment pathways based on individual patient profile utilising older and newer therapies appropriately, the QIPP prescribing comparator for diabetes is solely based on the use of low cost drugs relative to newer therapies.

3.3.2Medicine optimisation is about ensuring the right patients get the right choice of medicine at the right time and how patients comply. National measure of quality such as QIPP prescribing comparators and other outcome indicators should be focussed around NICE quality standards and guidance rather than stand-alone comparators that may encourage short-term savings that could have unintended costly consequences.

4. It is critical that we align how we measure and incentivise health-care professionals (& NHS England bodies) with national clinical guidelines on long-term condition risk factor management in order to address mortality rates and quality of life

4.1 Inconsistencies exist in national guidance for treating patients and how GPs are incentivised:

4.1.1For example, In the NICE Type 2 Diabetes Guideline (CG 87)127 it states, “Consider intensifying cholesterol-lowering therapy (with a more effective statin or cholesterol absorption inhibitor) in line with NICE guidance if there is existing or newly diagnosed cardiovascular disease, or if there is an increased albumin excretion rate, to achieve a total cholesterol level below 4.0 mmol/litre (and HDL cholesterol not exceeding 1.4 mmol/litre) or an LDL cholesterol level below 2.0 mmol/litre.”

4.1.2However, the Quality Outcomes Framework that incentivises GP states: The percentage of patients with diabetes, on the register, whose last measured total cholesterol (measured within the preceding 12 months) is 5 mmol/l or less and has an activity threshold of 40–75%.12

4.1.3The European Society of Cardiology/European Atherosclerosis Society Guidelines are even more stringent than UK NICE guidelines for very high risk patients, they recommend an LDL-C goal of 1.8 mmol/litre and/or 50% reduction when target level cannot be reached.13

4.2 The impact of factors on quality of life & productivity (such as the potential impact of hypoglycaemia in Type 2 diabetes) should be recognised, researched and acknowledged within NHS measures of long-term condition management quality throughout the system.

4.2.1For example, DVLA guidelines14 state for people with diabetes when treated with medication other than insulin which carries a risk of inducing hypoglycaemia (including sulphonylureas and glinides), the following standard applies in order to retain a driving licence:

Class 2 Drivers (buses and lorries)

There has not been any severe hypoglycaemic event in the previous 12 months.

Class 1 Drivers (cars and motorcycles)

Must not have had more than one episode of severe hypoglycaemia within the preceding 12 months.

The impact of hypoglycaemia on a person who is a professional driver or who drives regularly could be very significant on both quality of life and productivity if hypoglycaemia leads to losing their licence.

Similarly, in the elderly even a mild episode of hypoglycaemia may lead to adverse outcomes in frail elderly patients. For example, episodes of dizziness or weakness increase the risk of falls and fracture.15

The NICE Quality Standard for Diabetes16 recognises the importance of hypoglycaemia and includes a measure that states: “People with diabetes who have experienced hypoglycaemia requiring medical attention are referred to a specialist diabetes team”.

Quality measures recognising factors such as hypoglycaemia monitoring and/or management, should also be incentivised in QOF and CCG Outcome Indicators.

5. Quality measures need to go beyond “testing” alone to ensure risk factors are being effectively addressed nationwide and to further narrow inequalities

5.1 Although testing, such as the nine Key Care Processes for Diabetes, are important testing alone cannot make a difference to outcome, healthcare professionals need to ensure action is taken on the results of tests to ensure that people’s long-term condition and risk-factors are being managed effectively.119 Quality measures and outcome indicators throughout the NHS system (eg CCG outcome indicators) should reflect this.

5.2 For example in diabetes, even where testing is taking place, many patients are not achieving the recommended target range for risk factors (eg although 90% of Type 2 Diabetes patients are having their HbA1c and cholesterol tested, only 60% are achieving target HbA1c levels and only 40% are achieving their target cholesterol level in England)³.

5.3 Access to education of the patient and care planning is of paramount importance.119 A patient should be informed and enabled to take a role in self-management of diabetes risk-factors and understand factors such as the importance of optimal blood glucose control in order to avoid serious complications.

6. With the creation of NHS England and the removal of certain information & education structures (eg NHS diabetes) it is key that new support structures are adopted rapidly in order to offer practical assistance to commissioners

6.1 With the dissolution of NHS Diabetes, there is a gap in support & education for development of commissioning for diabetes services at the very time when it is most needed.

6.2 There are a wide number of data sets available for CVD and diabetes but they are often difficult to interpret and support is required on how to utilise these and help in practical implementation of commissioning.

7. There are a number of examples of effective integration of services across health, social care and other services which treat and manage long-term conditions

7.1 First Diabetes (Derbyshire) is a current of example of how integrated care can provide real improvements in care for diabetic patients, whist reducing admission rates.17

7.2 See earlier example of EiP⁹ example, paragraph 3.2.1.

8. With an increasing ageing population it is key that more is done to address disease management of long-term conditions in the community-setting in order to improve mortality rates, quality of life and prevent costly hospital admissions and care. This should be supported by appropriate measurement and outcome indicators

8.1 Diabetes cost approximately £23.7 billion in the UK in 2010–11: £9.8 billion in direct costs (£1 billion for Type 1 diabetes and £8.8 billion for Type 2 diabetes) and £13.9 billion in indirect costs (£0.9 billion and £13 billion). In real terms, the 2035–36 cost is estimated at £39.8 billion: £16.9 billion in direct costs (£ 1.8 billion for Type 1 diabetes and £15.1 billion for Type 2 diabetes) and £22.9 billion in indirect costs (£2.4 billion and £20.5 billion).18

8.2 It is key that there is a shift in focus from short-term cost-cutting in the community-setting to more efficient use of NHS resources, by effective prevention, diagnosis and risk-factor management to avoid costly complications and hospital treatment. This should be supported by appropriate measurement and outcome indicators.

9 May 2013