Transcript No Slide Title

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
PAHO/WHO Seminar
Brasilia October 2002
BACKGROUND
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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
PAHO/WHO Seminar
Brasilia October 2002
NHS IN ENGLAND
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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
PAHO/WHO Seminar
Brasilia October 2002
NHS RESOURCE ALLOCATION
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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
PAHO/WHO Seminar
Brasilia October 2002
PRESCRIBED MEDICINES IN ENGLAND
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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.
PAHO/WHO Seminar
Brasilia October 2002
GOVERNMENT STRATEGY FOR
PHARMACEUTICALS: POLICY OBJECTIVES
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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
PAHO/WHO Seminar
Brasilia October 2002
ACCESS TO MEDICINES
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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
PAHO/WHO Seminar
Brasilia October 2002
LOGISTICS AND SUPPLY
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Primarily by private sector
Manufacturers and wholesalers
- two large national wholesalers, AAHGEHE and Unichem, both also have
chains of pharmacies
Hospitals make national or regional
contracts through NHS Logistics with some
NHS warehousing and distribution
PAHO/WHO Seminar
Brasilia October 2002
PRICE REGULATION
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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)
PAHO/WHO Seminar
Brasilia October 2002
MANAGEMENT SYSTEMS: CONTROL AND
EVALUATION OF PHARMACEUTICALS STRATEGY
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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
PAHO/WHO Seminar
Brasilia October 2002
GROWTH IS DRIVEN BY CLINICAL PRIORITIES:
NHS NATIONAL SERVICE FRAMEWORKS
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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)
PAHO/WHO Seminar
Brasilia October 2002
Spend on statins in an English health authority
(population 1.5 m)
(Source: Steve Chapman, Keele University, UK)
£6,000,000
£5,000,000
£4,000,000
£3,000,000
£2,000,000
£1,000,000
Spend
PAHO/WHO Seminar
Dec-03
Jun-03
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£0
01/06/96
Spend by quarter
£7,000,000
Predicted Spend
Brasilia October 2002
Spend on antidiabetic drugs in an English
health authority (population 1.5 m)
(Source: Steve Chapman, Keele University, UK)
£3,000,000
£2,500,000
£2,000,000
£1,500,000
£1,000,000
£500,000
Spend
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£0
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Spend per quarter
£3,500,000
Predicted Spend
Brasilia October 2002
Spend on atypical antipsychotics in an English
health authority (population 1.5 m)
(Source: Steve Chapman, Keele University, UK)
£3,500,000
£3,000,000
£2,500,000
£2,000,000
£1,500,000
£1,000,000
£500,000
Spend
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£0
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Spend per quarter
£4,000,000
Predicted Spend
Brasilia October 2002
Spend on nicotine replacement therapy (NRT) in an
English health authority (population 1.5 m)
(Source: Steve Chapman, Keele University, UK)
£250,000
£200,000
£150,000
£100,000
£50,000
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£0
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Spend per quarter
£300,000
Brasilia October 2002
SUBOPTIMAL CARE: HYPERTENSION
THERAPY IS OFTEN ABSENT OR INEFFECTIVE
All adults
Normal
blood pressure
82%
18%
People with
high blood pressure
33%
TREATED - blood
pressure controlled
19%
TREATED - blood
pressure not controlled
48%
Not currently taking
medication prescribed
for high blood pressure
All adults aged 16 and over, England
Source: Health Survey for England, 1998
PAHO/WHO Seminar
Brasilia October 2002
Spend on ACE Inhibitors and AIIRAs (population
1.5 m)
(Source: Steve Chapman, Keele University, England)
£7,000,000
£6,000,000
£5,000,000
£4,000,000
£3,000,000
£2,000,000
£1,000,000
Angio Spend
Predicted Angio Spend
ACE Spend
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£0
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Spend per quarter
£8,000,000
Predicted Ace Spend
Brasilia October 2002
PRIMARY CARE PRESCRIBING IN ENGLAND:
THERAPEUTIC AREAS DRIVING COST GROWTH
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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
PAHO/WHO Seminar
Brasilia October 2002
NEW DRUGS: NATIONAL INSTITUTE FOR
CLINICAL EXCELLENCE (1999)
PURPOSE
“To provide health professionals in England
and Wales with advice on securing the
highest attainable standards of care for
National Health Service patients”
PAHO/WHO Seminar
Brasilia October 2002
WHY WAS NICE CREATED?
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To minimise inappropriate variations in
clinical practice
To provide clear standards based on
clinical and cost effectiveness
To resolve uncertainty
PAHO/WHO Seminar
Brasilia October 2002
NICE: SOME CURRENT PROGRAMMES
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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
PAHO/WHO Seminar
Brasilia October 2002
GENERIC MEDICINES
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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
PAHO/WHO Seminar
Brasilia October 2002
INCREASE IN GENERIC PRESCRIBING RATES IN
AN ENGLISH REGION
1994-2001
100.00
90.00
% generic prescribing rate
80.00
PSA target
70.00
60.00
50.00
40.00
30.00
20.00
10.00
0.00
9495Q4
9596Q4
9697Q4
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9899Q4
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0102Q4
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Northern and Yorkshire: BNF 2.02 - Diuretic expenditure
140,000
120,000
Sunderland
Northumberland
100,000
North Cumbria
Wakefield
GST
80,000
NIC (£)
Bradford
NNT
Calderdale & Kirklees
60,000
East Riding
Tees
County Durham
40,000
North Yorkshire
Leeds
20,000
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PAHO/WHO Seminar
Brasilia October 2002
(1)
Price Index of 343 generic preparations in the
Maximum Price Scheme (Base = Jan 2000)
1.00
Introduction of Maximum Price Scheme
0.90
Consultation on
Maximum Price
Scheme announced
0.80
0.70
PAHO/WHO Seminar
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Jan-02
Nov-01
Sep-01
Jul-01
May-01
Mar-01
Jan-01
Nov-00
Sep-00
Jul-00
May-00
Mar-00
0.60
Jan-00
Price Index (Base = Jan 2000)
1.10
Brasilia October 2002
PHARMACEUTICALS STRATEGY IN THE UK:
SUMMARY
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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
PAHO/WHO Seminar
Brasilia October 2002