Health CommitteeWritten evidence from the Association of the British Pharmaceutical Industry (LTC 77)

Introduction

The ABPI represents innovative research-based biopharmaceutical companies, large, medium and small, leading an exciting new era of biosciences in the UK.

Our industry, a major contributor to the economy of the UK, brings life-saving and life-enhancing medicines to patients. Our members supply 90% of all medicines used by the NHS, and are researching and developing over two-thirds of the current medicines pipeline, ensuring that the UK remains at the forefront of helping patients prevent and overcome diseases.

The ABPI is recognised by Government as the industry body negotiating on behalf of the branded pharmaceutical industry, for statutory consultation requirements including the pricing scheme for medicines in the UK.

The ABPI welcomes the opportunity to submit evidence to the Committee’s inquiry on long term conditions. As the trade association representing companies who develop and supply medicines across a wide range of long term conditions our submission concentrates on the role of medicines and biopharmaceutical companies working in partnership with the NHS across all long term conditions which we hope will be helpful across all the questions the committee is considering.

Already, 15 million people in England have long term conditions, accounting for 70% of health and social care spending and these figures are rising. ABPI welcomes the Government’s commitment to make England one of the best countries in Europe at helping people with long term conditions live healthily and independently. The biopharmaceutical industry also wants to support people with long term conditions to live healthily and independently.

The ABPI welcome the aims outlined in the Department of Health’s “Living Well for Longer: A call to action to reduce avoidable premature mortality” and improving the UKs position relative the other European countries.

It is worth highlighting that significant numbers of people (7.8 million) live with chronic pain and the burden in terms of cost to the NHS is often underestimated. Whilst this is not always recognised in the NHS as a long term condition in itself it frequently co exists with a range of long term conditions.

1. Medicines Optimisation

1.1 Medicines form a key part of the management of long term conditions. Ensuring that that patients gain the maximum benefit from their medicines is crucial both for patient outcomes and the effective use of NHS resources in line with the aims laid out in “The Mandate” (Department of Health November 2012).

1.2 Medicines management, as practiced in the NHS in recent years, has focused on making short term savings by curtailing spend on medicines. The ABPI therefore welcomes NHS England’s focus on medicines optimisation in place of medicines management, and specifically the importance this places on innovation. The ABPI believes that medicines optimisation should focus on improving healthcare outcomes for patients by realising better value from the investment in medicines. For people with long term conditions, who may receive treatment with medicines for all of their lives, the concept of medicines optimisation is particularly relevant.

1.3 The UK spends only 0.9% of GDP on medicines—less than the European average of 1.2%. The percentage of the NHS budget spent on medicines has fallen since 1999—down from 13% to a little under 10%. A focus on cutting the cost of medicines spend through medicines management programmes has already delivered significant savings for the NHS, and continued focus on spend will not be sustainable at this rate without having a detrimental impact on patient outcomes.

1.4 Medicines optimisation is all about having a patient centred approach to medicines use, making sure we improve patient outcomes, reduce wastage, improve safety, increase compliance and realise the full value of medicines as a consequence. Correctly used, medicines have the potential to:

Improve outcomes and the quality of life for patients.

Prevent expensive healthcare interventions such as additional healthcare professional visits and unplanned hospitalisations.

Prevent costly progression of disease.

Enable the redesign of pathways of care to extract maximum value from the medicine and the local health and social care resources.

Reduce adverse events, waste and errors that cost the local health economy a significant amount each year and adversely affect patients’ lives.

Improve patients’ adherence to treatment regimes.

1.5. The ABPI believes that medicines optimisation should rightly focus on medicines safety, adherence and reducing wastage, and also ensure that the intrinsic value of medicines in improving healthcare outcomes for patients is realised. Medicines optimisation is the key to ensuring the right patients get the right medicine, at the right time and in turn improving adherence, reducing waste and eliminating harm due to inappropriate medicines use or prescribing.

1.6. The ABPI supports the Royal Pharmaceutical Society’s four guiding principles for medicines optimisation:

Aim to understand the patient’s experience.

Evidence based choice of medicines.

Ensure medicines use is as safe as possible.

Make medicines optimisation part of routine practice.

1.7. The ABPI recommends that a whole system approach is taken on medicines optimisation. Community pharmacy should have a prominent role in delivering the medicines optimisation agenda, and all relevant organisations should adopt national medicines optimisation policies.

1.8. The ABPI recommends that local implementation metrics reflect the national medicines optimisation agenda. The ABPI further recommends that clear support and guidance is offered on a national level on how medicines optimisation can be implemented and delivered locally.

2. Case Study: Medicines Optimisation and Atrial Fibrillation

2.1 The case of study below demonstrates how innovative medicines can significantly improve and change a patient pathway.

2.2 Atrial fibrillation (AF) is the most common sustained heart arrhythmia and is characterised by an erratic and often rapid heart rhythm. This long term condition is estimated to affect in excess of one million people in the UK, with 200,000 patients being newly diagnosed each year. With an ageing population, the AF population is set to double in the next forty years. AF is a major cause of stroke, meaning that Patients with AF can often be a “walking time bomb” unless they receive appropriate and well-managed anticoagulation. It is estimated that 12,500 strokes are directly attributable to AF each year.1 The prevalence of AF increases rapidly with age as the incidence of resulting strokes rises from 1.5% among people ages 50–59 to 23.5% among people aged 80–89.2

2.3 It is estimated that stroke care costs the NHS £2.2 billion3 in direct care costs and costs the wider economy an additional £1.8 billion in loss of productivity and disability. Indirect care costs, such as home nursing, are estimated to be £2.4 billion. Annually, stroke patients occupy up to a quarter of total hospital bed days. Given the increased severity of AF-related strokes and the fact that AF-related stroke patients have longer hospital stays than other stroke patients, AF-related strokes are costly to the NHS to manage—the cost per stroke due to AF is estimated to be £11,900 in the first year after stroke occurrence.

2.4 AF-related stroke can be prevented through anticoagulation. Historically the only anticoagulant available has been warfarin. Patients receiving warfarin need to have their INR frequently monitored. This generally represents a trip to hospital, GP or a pharmacy-led clinic every two—four weeks, and poses significant time burden on people with AF. The estimated costs for a visit to an anticoagulation clinic are £17 for the first appointment and £18 for each subsequent visit.4

2.5 The Novel Oral AntiCoagulants (NOACs) mean that whilst patients require some monitoring they require significantly fewer visits to hospitals. The NOACs have been approved by NICE for the prevention of AF-related stroke as clinically effective for use on the NHS.

2.6 Evidence suggests that commissioners at the local NHS level are slow to implement the NICE guidance which recommends NOACs for use in the NHS. There is anecdotal evidence that this is due to concerns about the higher prescribing cost associated with these newer treatments when compared to the cost of warfarin.

2.7 While the daily cost of NOACs is certainly higher than the daily cost of warfarin, warfarin prescribing costs cannot be disassociated from the infrastructure costs of the anticoagulation clinics required for INR monitoring. The additional infrastructure costs for warfarin—not required for NOACs—adds significantly to the true cost of using warfarin, and therefore reduces the overall cost difference between warfarin and NOACs. Also the NOACs have additional clinical and practical advantages over warfarin which could lead to fewer clinical events. This was recognised in the recent “Catalogue of Potential Innovations” published by the Department of Health in March 2013. Service improvement leads are encouraged to take up the innovations in this publication.

2.8 Despite NICE guidance recommending NOACs as cost effective treatment options to be considered alongside warfarin, uptake of the medicines, and the innovation they bring, has been slow in some parts of the country due to restrictions at a local level in terms of formularies, local protocols and pathways. This suggests a focus on short term cost savings that can be associated with the medicines management approach outlined above. A medicines optimisation approach, with better outcomes for patients at its centre, would suggest that the improved outcomes and long term value for money would make an investment in NOAC treatment worthwhile.

2.9 Whilst the Government’s recently published National Cardiovascular Disease Outcomes Strategy, which mentions AF is to be welcomed, it contains no recommendations for NHS policy interventions to incentivise improvement detection, management and treatment of AF to achieve stroke prevention and associated mortality reduction.

3. Joint Working

3.1 Pharmaceutical companies can improve the care for patients with long term condition by Joint Working programmes with the NHS.

3.2 Joint working is where pharmaceutical companies pool skills, experience and/or resources with the NHS for the joint development and implementation of patient-centred projects. All joint working projects are carried out expressly and primarily for the benefit of patients. Joint working has already benefited thousands of patients across the UK with projects assisting in the reduction of COPD admissions, improvements in vascular checkups and improved outcomes for diabetes patients.

3.3 The pharmaceutical industry has considerable commercial experience and management expertise that can be brought to joint working projects. Companies also have valuable experience and knowledge of the disease areas for which they provide treatments. It is important that the NHS is able to access these resources as a spur for innovation in caring for people with long term conditions, and that successful innovations are spread throughout the NHS.

3.4 Examples of successful joint working include a project in Nottingham to reduce COPD exacerbations. A clinical audit and treatment review of all Nottingham City patients admitted to Nottingham University Hospitals NHS Trust with an exacerbation of their COPD was carried out and analysis of the data enabled identification of whether care prior to admission had been managed according to the NICE clinical guideline. It also enabled identification of areas of potential improvement in local care pathways and treatment guidelines. Service changes now include: development and implementation of a personalised self management plan for all patients with COPD; treatment reviews of all patients with COPD who have had one or more exacerbations in the previous 12 months to ensure they are being managed in line with NICE guidelines using four respiratory nurse specialists seconded to the programme from company partners; development and implementation of a bespoke COPD clinical management template for GP clinical systems; primary care professional training and education.

3.5 In Haringey, an innovative, long term conditions pilot programme was launched in 2004 to provide person-centred, telephone-based support for 600 patients with diabetes, heart failure and coronary heart disease by supporting them to take a more informed and active role in their healthcare. A team of dedicated care managers, all of whom were qualified nurses, provided assessment, care planning, regular coaching and support for patients based on their individual needs, signposting them to other services as appropriate. They used decision support software to facilitate proactive communication with patients, and which also provided and recorded information for ongoing care management. The expectation of the programme was that, through regular communication, patients would become more successful in managing their condition and improve their clinical outcomes and quality of life, while reducing the demands on local health services.

9 May 2013