Experience in the UK National Health Service Dr Jim Smith Chief Pharmaceutical Officer

PAHO/WHO Seminar Brasilia October 2002

PAHO/WHO INTERNATIONAL SEMINAR ON CHALLENGES FOR COMPREHENSIVE

PHARMACEUTICAL SERVICES

BRASILIA, OCTOBER 2002

Experience in the UK National Health Service

Dr Jim Smith

Chief Pharmaceutical Officer

Department of Health, England, UK


BACKGROUND

UK National Health Service (NHS) since 1948 Funded through tax revenues Free at point of use

- nb dental, optical, prescription charges

Locally managed Funding, strategy set by central government Small insurance-based private sector (<10%) Devolution - Scotland, Wales, N Ireland


NHS IN ENGLAND

Strategy, standards, funding set centrally Local management by 305 primary care

trusts (PCTs) - commission hospital services - contract with practitioners for 1ary

care (also increasing direct provision) Direct allocation of funds to PCTs Strategic health authorities (28)

- performance management role


NHS RESOURCE ALLOCATION

Agreed by Ministers - advisory committee for resource allocation, weighted capitation model

Unified allocations to PCTs (‘cash limited’) - cover hospital & community services, primary care services, pharmaceuticals

PCTs set drug budgets within overall allocation ‘Indicative’ drug budget for each GP practice Hospital drugs within total hospital funding


PRESCRIBED MEDICINES IN ENGLAND

Most frequent clinical intervention - 550 M GP Rx (11 per person) and 200 M in hospitals p.a

£1.5 B spent on hospital medicines each year (c. 5% of revenue)

£5.6 B in primary care (c. 50% of revenue) Overall, >15% of NHS revenue Current real growth of about 12-15% p.a.


GOVERNMENT STRATEGY FOR PHARMACEUTICALS: POLICY OBJECTIVES

Convenient and appropriate access to medicines for patients

Medicines appropriately and effectively prescribed and used

Appropriate uptake of new treatments Good value for the NHS from supply chain

with fair returns for suppliers Strong and competitive UK pharmaceutical

industry


ACCESS TO MEDICINES

Generally very good Doctors enjoy substantial clinical freedom Prescribing within budgetary framework in

hospitals and primary care No national drug list Ministers have powers to restrict drugs

- used sparingly, eg viagra Local formularies - usually not mandatory Access to new drugs - NICE


LOGISTICS AND SUPPLY

Primarily by private sector Manufacturers and wholesalers

- two large national wholesalers, AAH- GEHE and Unichem, both also have chains of pharmacies

Hospitals make national or regional contracts through NHS Logistics with some NHS warehousing and distribution


PRICE REGULATION

Branded products - pharmaceutical price regulation scheme (PPRS) negotiated between central Government and industry (ABPI) - model takes into account return on capital, R&D spend etc for each company

Generics - no price regulation prior to 2000 - maximum price scheme (under review)


MANAGEMENT SYSTEMS: CONTROL AND EVALUATION OF PHARMACEUTICALS STRATEGY

Cash limits on NHS bodies Indicative drug budgets for GPs Performance management by strategic

health authorities and, exceptionally, DH Powerful data system for GPs - operated by

Prescription Pricing Authority (PPA) - provides detailed feedback for clinical and financial management

National Audit Commission


GROWTH IS DRIVEN BY CLINICAL PRIORITIES: NHS NATIONAL SERVICE FRAMEWORKS

Mental health (September 1999) Coronary heart disease (March 2000) Cancer plan (October 2000) Older people (March 2001)

Diabetes (2002) Children (?2002) Long term conditions (2002-3)


Spend on statins in an English health authority (population 1.5 m)

(Source: Steve Chapman, Keele University, UK)

£0

£1,000,000

£2,000,000

£3,000,000

£4,000,000

£5,000,000

£6,000,000

£7,000,000

01/0

6/96

01/1

2/96

01/0

6/97

01/1

2/97

01/0

6/98

01/1

2/98

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6/99

01/1

2/99

01/0

6/00

01/1

2/00

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6/01

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2/01

01/0

6/02

01/1

2/02

Jun

-03

Dec

-03

Sp

end

by

qu

arte

r

Spend Predicted Spend


Spend on antidiabetic drugs in an English health authority (population 1.5 m)


£0

£500,000

£1,000,000

£1,500,000

£2,000,000

£2,500,000

£3,000,000

£3,500,00001

/06/

96

01/1

2/96

01/0

6/97

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2/97

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6/98

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2/02

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01/1

2/03

Sp

end

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qu

arte

r



Spend on atypical antipsychotics in an English health authority (population 1.5 m)


£0

£500,000

£1,000,000

£1,500,000

£2,000,000

£2,500,000

£3,000,000

£3,500,000

£4,000,0000

1/0

6/9

6

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/12

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Sp

end

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Spend on nicotine replacement therapy (NRT) in an English health authority (population 1.5 m)


£0

£50,000

£100,000

£150,000

£200,000

£250,000

£300,0000

1/0

6/9

6

01

/12

/96

01

/06

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Sp

end

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SUBOPTIMAL CARE: HYPERTENSION THERAPY IS OFTEN ABSENT OR INEFFECTIVE

All adults aged 16 and over, England

Source: Health Survey for England, 1998

82%

18%People with

high blood pressure

19%

33%

48%

Normalblood pressure

All adults

TREATED - blood pressure controlled

TREATED - blood pressure not controlled

Not currently taking medication prescribed for high blood pressure


Spend on ACE Inhibitors and AIIRAs (population 1.5 m) (Source: Steve Chapman, Keele University, England)

£0

£1,000,000

£2,000,000

£3,000,000

£4,000,000

£5,000,000

£6,000,000

£7,000,000

£8,000,000

01/0

6/96

01/1

2/96

01/0

6/97

01/1

2/97

01/0

6/98

01/1

2/98

01/0

6/99

01/1

2/99

01/0

6/00

01/1

2/00

01/0

6/01

01/1

2/01

01/0

6/02

01/1

2/02

01/0

6/03

01/1

2/03

Sp

end

per

qu

arte

r

Angio Spend Predicted Angio Spend ACE Spend Predicted Ace Spend


PRIMARY CARE PRESCRIBING IN ENGLAND: THERAPEUTIC AREAS DRIVING COST GROWTH

Growth (%) Impact (%) Lipid regulating drugs 32.6 19.1 Antihypertensives 17.7 11.0 Anti-diabetic drugs 22.7 9.1 Antidepressants 14.0 7.2 Antipsychotic drugs 31.5 5.3

Source: Dave Roberts, Prescribing support Unit,

Leeds, UK, 2002


PURPOSE

“To provide health professionals in England and Wales with advice on securing the highest attainable standards of care for National Health Service patients”

NEW DRUGS: NATIONAL INSTITUTE FOR CLINICAL EXCELLENCE (1999)


WHY WAS NICE CREATED?

To minimise inappropriate variations in clinical practice

To provide clear standards based on clinical and cost effectiveness

To resolve uncertainty


NICE: SOME CURRENT PROGRAMMES

Appraisals of individual health technologies Guidelines for the management of individual

conditions Assessment of new interventional procedures

Debate about ‘rationing’ but NICE is estimated to have facilitated £300 m

new drugs for 1.5 m patients - cancer, CHD, arthritis, Alzheimers


GENERIC MEDICINES

Generic prescribing has been Government policy for c. 20 years

Not mandatory Substitution not permitted in primary care Substantial savings Price volatility in 1999-2000 Maximum price scheme Pricing & supply under review by Ministers


0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

90.00

100.00

9495Q4 9596Q4 9697Q4 9798Q4 9899Q4 9900Q4 0001Q4 0102Q4

% g

eneri

c p

resc

ribin

g r

ate PSA target

INCREASE IN GENERIC PRESCRIBING RATES IN AN ENGLISH REGION 1994-2001


Northern and Yorkshire: BNF 2.02 - Diuretic expenditure

-

20,000

40,000

60,000

80,000

100,000

120,000

140,000

NIC

(£)

Sunderland

Northumberland

North Cumbria

Wakefield

GST

Bradford

NNT

Calderdale & Kirklees

East Riding

Tees

County Durham

North Yorkshire

Leeds


Price Index (1) of 343 generic preparations in the Maximum Price Scheme (Base = Jan 2000)

0.60

0.70

0.80

0.90

1.00

1.10

Jan-

00

Mar

-00

May

-00

Jul-0

0

Sep

-00

Nov

-00

Jan-

01

Mar

-01

May

-01

Jul-0

1

Sep

-01

Nov

-01

Jan-

02

Mar

-02

Pri

ce I

nd

ex

(B

ase

= J

an

200

0)

Introduction of Maximum Price Scheme

Consultation onMaximum PriceScheme announced


PHARMACEUTICALS STRATEGY IN THE UK: SUMMARY

Medicines predominantly provided by public sector (NHS) funded out of taxation

Small private sector (<10%) Logistics largely by private sector Central price controls on NHS medicines Pro-active management of cost and quality of

prescribing Advice on new drugs from NICE Major growth pressures at present

Documents

Experience in the UK National Health Service Dr Jim Smith Chief Pharmaceutical Officer