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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
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
Strategy, standards, funding set centrally Local management by 305 primary care trusts (PCTs)
- commission hospital services - contract with practitioners for 1 ary 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
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
Most frequent clinical intervention
- 550 M GP R x (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
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
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
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
PAHO/WHO Seminar Brasilia October 2002
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) PAHO/WHO Seminar Brasilia October 2002
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
PAHO/WHO Seminar Brasilia October 2002
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)
PAHO/WHO Seminar Brasilia October 2002
Spend on statins in an English health authority (population 1.5 m)
(Source: Steve Chapman, Keele University, UK)
£7,000,000 £6,000,000 £5,000,000 £4,000,000 £3,000,000 £2,000,000 £1,000,000 £0 Spend Predicted Spend
PAHO/WHO Seminar Brasilia October 2002
Spend on antidiabetic drugs 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 £0 Spend Predicted Spend
PAHO/WHO Seminar Brasilia October 2002
Spend on atypical antipsychotics in an English health authority (population 1.5 m)
(Source: Steve Chapman, Keele University, UK)
£4,000,000 £3,500,000 £3,000,000 £2,500,000 £2,000,000 £1,500,000 £1,000,000 £500,000 £0 Spend Predicted Spend
PAHO/WHO Seminar Brasilia October 2002
Spend on nicotine replacement therapy (NRT) in an English health authority (population 1.5 m)
(Source: Steve Chapman, Keele University, UK)
£300,000 £250,000 £200,000 £150,000 £100,000 £50,000 £0
PAHO/WHO Seminar Brasilia October 2002
SUBOPTIMAL CARE: HYPERTENSION THERAPY IS OFTEN ABSENT OR INEFFECTIVE All adults 82 % 18 % Normal blood pressure People with high blood pressure 33 19 % 48 % % TREATED - blood pressure controlled TREATED - blood pressure not controlled 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)
£8,000,000 £7,000,000 £6,000,000 £5,000,000 £4,000,000 £3,000,000 £2,000,000 £1,000,000 £0 Angio Spend Predicted Angio Spend ACE Spend Predicted Ace Spend
PAHO/WHO Seminar Brasilia October 2002
PRIMARY CARE PRESCRIBING IN ENGLAND: THERAPEUTIC AREAS DRIVING COST GROWTH
Lipid regulating drugs Antihypertensives Anti-diabetic drugs Antidepressants Antipsychotic drugs Growth (%) Impact (%) 32.6
17.7
22.7
14.0
31.5
19.1
11.0
9.1
7.2
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?
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 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
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
80.00
70.00
60.00
50.00
40.00
30.00
20.00
10.00
0.00
9495Q4 9596Q4 9697Q4 9798Q4 9899Q4 9900Q4 0001Q4 0102Q4 PSA target
PAHO/WHO Seminar Brasilia October 2002
Northern and Yorkshire: BNF 2.02 - Diuretic expenditure
140,000 120,000 100,000 80,000 60,000 40,000 20,000 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 0 1 2 1 2 3 4 5 6 7 8 9 19 970 19 970 19 970 19 970 19 971 19 971 19 971 19 980 19 980 19 980 19 980 19 980 19 980 19 980 19 980 19 980 19 981 19 981 19 981 19 990 19 990 19 990 19 990 19 990 19 990 19 990 19 990 19 990 19 991 0 Sunderland Northumberland North Cumbria Wakefield GST Bradford NNT Calderdale & Kirklees East Riding Tees County Durham North Yorkshire Leeds
PAHO/WHO Seminar Brasilia October 2002
Price Index (1) of 343 generic preparations in the Maximum Price Scheme (Base = Jan 2000)
1.10
1.00
0.90
0.80
Consultation on Maximum Price Scheme announced
0.70
0.60
Introduction of Maximum Price Scheme
PAHO/WHO Seminar Brasilia October 2002
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
PAHO/WHO Seminar Brasilia October 2002