Most people with multiple sclerosis (MS) in the UK do not receive medication that could alleviate their symptoms and delay the progression of the disease.

A survey of over 10,000 patients by the MS Society found access to drugs was 68% in Northern Ireland, 40% in England, 36% in Scotland and 30% in Wales.

The charity said that limited patient access to specialists was the main reason for the prevalence of under-treatment.

Only two other EU countries, Poland and Romania, had a lower level of uptake of medication for the disease.

The relatively high level of medication for MS in Northern Ireland reflects the fact that only that country offers patients a twice-yearly review with a specialist.

The MS Society called for the NHS to provide every MS patient with a personalised care plan.

The study found that 41% of patients who said they had enough information about drugs still did not take one.

It concluded: “This could be due to barriers to accessing medicines; because individuals make an informed decision not to take them; or because they don't know what information is out there, such as around new treatments or new evidence of efficacy.”

Nick Rijke, Director for Policy and Research at the MS Society, commented: “These findings worryingly suggest that the likelihood of someone receiving a life-changing treatment is often based on luck – like where they live or how helpful their healthcare professional is.”

The Society noted that NHS rationing was denying many patients access to the more expensive MS drugs, even though these might be more effective.

MS affects about 100,000 people in the UK, three quarters of them female.

The ‘Nicholson challenge’ of NHS cost-cutting is being met through “short-term fixes” that block service redesign, according to the Commons Health Select Committee.

The three main methods used to reduce NHS costs have been tariff reduction, staff pay freezes and ‘salami slicing’ of providers, the MPs noted.

The Committee also observed that NHS cost savings being ‘clawed back’ by the Treasury defeated the stated aim of the savings: to create funding for service redesign that would reduce long-term costs and improve performance.

In contrast, it said, the means being used to cut £6bn each year from the NHS budget were not sustainable and harmed services.

The report found that in 2011–12, £2.4bn was saved through tariff reductions and £850m through pay freezes, with similar cuts planned for 2012–13.

It warned that these and other “short-term fixes” would be “increasingly difficult” to repeat, and that NHS commissioners needed to aim at “genuine and sustained service integration.”

Chair Stephen Dorrell said the reliance on tariff reduction “tends to have an undesirable effect of encouraging salami slicing of individual providers rather than imaginative system redesign.”

In addition, he argued, “it gives the commissioners a cop-out” when they “ought to be stage centre in the process of service re-imagination”.

The Committee warned that assuming “NHS pay will continue to fall relative to pay elsewhere in the economy” was “neither prudent nor just”.

It recommended that NHS commissioners and providers be allowed to use cash reserves to fund service change, rather than lose them to the Treasury.

Mike Farrar, Chief Executive of the NHS Confederation, commented: “We need to look beyond the short-term options and consider more radical solutions that will improve care in the long term.”

In the new Pf, Health Secretary Jeremy Hunt answers some questions from our readers. Maxine Vaccine delivers a brief audit report on his answers.

The most vital thing to remember about Jeremy Hunt is that he’s not Andrew Lansley. The older man spent nine years dreaming up a transformation of the NHS into a competitive healthcare market system, then claimed he’d had to invent it out of thin air when, as part of the new coalition government, he “saw the books” (which he’d had full access to for nine years) for the first time. Then he drove through legislation designed to break up the NHS and place its fragments on the bargain shelf of global corporate business, and mocked anyone who questioned it. Forced into a cosmetic display of ‘consultation’, he followed it up by declaring that the ‘listening period’ had been needed only to educate the ignorant doctors.

And suddenly, the Tories are faced with the prospect of losing power. Journalists are calling the Health and Social Care Act ‘Cameron’s poll tax’. Cue the new Department of Health. Exit the sneering headmaster and enter the elegantly half-smiling head boy. Who doesn’t half scrub up well, and – unlike Lansley – can say “the NHS is one of our greatest assets” without crossing his fingers behind his back. Jeremy Hunt was a contributor to Direct Democracy (2005), a Conservative Party activist guide that claimed the NHS was “no longer relevant” to modern society because it was a public sector health system. But he can say “the NHS is one of our greatest assets” because he can say anything. Lansley is a Thatcher type of politician, whereas Hunt is a Blair type.

His answers to the Pf questions are classic examples of why he has been drafted in to front NHS reform up to the next General Election, or at least part-way there. He never says the wrong thing. If he can’t say the right thing, he says nothing in a nice way. He makes you feel that anyone who disagrees with him must be insane. It’s only when you compare his words with what is actually going on that things get complicated – and you realise that, as a new lease-holder in the house that Lansley built, he has only unpacked the suitcases for two rooms: the front room and the bathroom. The rest of the house is unoccupied.

Regular Pf contributor Omar Ali asked Hunt a question about NHS rationing: how will making patients pay for services be integrated into the wider healthcare bill implementation? A good question, as this is already happening: patients in many areas are being told they cannot have cataract operations, varicose vein surgery or hip/knee replacements unless either (a) they wait until their need is greater (for example, they can have cataract surgery once they are blind) or (b) they go private. Referral management, which Sir David Nicholson is very keen on, is another form of rationing: if patients want to see a specialist in many situations, they have to go private. Hunt’s response is worth quoting in full:

Let me be absolutely clear on this – the NHS will always be free at the point of delivery and no one will be asked to pay for its services. Yes, in the future, services will be provided differently – public health services will be organised by local authorities, for example – but the founding principle of those NHS services being free, for those who need it, will never change.

Hunt is neatly splitting the hair of Omar Ali’s question. If people are paying for services they are not NHS services, they are private. But money will still be changing hands for services that used to be free. They just won’t be NHS services any more. And that “for those who need it” is significant. It has two aspects: severity of clinical need (already a moveable famine) and ability to pay (Direct Democracy suggests the NHS should become a means-tested state reimbursement of private healthcare fees). Who needs free healthcare, and what free healthcare they need, will be critical issues from now on – and legally, the Health Secretary now has no remit to influence those decisions, which will be made by autonomous CCGs and/or the autonomous Commissioning Board.

Pf reader Susan Ranch asked whether the Government’s recent announcement that it will cap individual payments for social care at twice the Dilnot-recommended level means that more NHS funding will be committed for elderly patients. Hunt replied: This is incorrect. The Government has not said this and no decision has been made. Strictly speaking, he is right. According to the BBC and three Tory-loyal newspapers (the Sunday Times, the Daily Mail and the Daily Express), journalists were briefed that setting the social care payment cap at £75k (whereas Dilnot had recommended £35k) would feature in the Government’s mid-term review. But it did not – and the critical backlash from social and healthcare experts was either unnecessary or effective, depending on your interpretation. Whatever its level, the cap appears unlikely to be implemented before the 2015 election.

Hunt went on to say: I want this country to become one of the best places in Europe to grow old and make sure people can live independent and healthier lives into old age. Which is the kind of gold-plated soundbite Lansley never delivered.

Another Pf reader, Leigh Saunders, asked how the pharmaceutical industry could work with the NHS to improve cancer survival rates. Hunt replied: The pharmaceutical industry already plays a vital role in improving the health of people with cancer. I want to improve mortality rates, where the targeting and development of medicines is becoming ever more important. I am sure the pharmaceutical industry will want to build on its work in this area and help improve cancer care.

Great stuff: that flatters the industry, expresses a decent medical aim, and then flatters the industry again. It doesn’t answer the question, but who cares?

Jeremy Hunt’s management of the Pf questions is a masterclass in accessible spin. It tells us almost nothing about Government policy, but it tells us why Hunt currently holds the lease on the house of NHS reform. He knows how to make it look good – and in politics, that’s not always easy. The pharma industry should recognise Hunt’s talents as those of marketing and sales. He’s one of us.

Maxine’s views and attitude are not necessarily those of Pf.

Is QIPP really about ‘doing more with less’?

The NHS Quality, Innovation, Productivity and Prevention (QIPP) Challenge was launched in March 2010 as a strategy to facilitate major cost savings within the NHS, in response to the impact of the global recession. The principle of QIPP was that given the need for austerity budgeting, serious planning and rethinking were needed to ensure ‘smart’ cost-cutting that did not harm patient outcomes. The QIPP agenda was about identifying solutions that held together the four key principles, reducing overall costs by making interventions more timely, efficient and effective.

The new Government’s NHS reforms promised to facilitate QIPP by empowering local providers and commissioners to develop the best solutions for their communities. However, the economic pressures on CCGs and Foundation Trusts within the new system, combined with the ‘Nicholson challenge’ of cutting £5 billion out of the NHS budget in each of four successive years, have meant that the dominant theme of QIPP at a local level is cost reduction.

The first full year of QIPP (2011–12) delivered savings of £5.8 billion against a target of $5 billion. However, reports of NHS rationing and ‘postcode prescribing’ have proliferated. QIPP was devised as a strategy to combine two goals: the shift towards community-based healthcare and the urgent drive towards NHS cost-cutting. Is that still the agenda, or have the pressures of NHS reform reduced its four principles to one: reducing expenditure? Is QIPP really about “doing more with less”, as Andrew Lansley claimed, or is it just about doing with less?

A new healthcare paradigm
The DH booklet introducing the QIPP challenge in March 2010 set the context: “The NHS needs to identify £15–20 billion of efficiency savings by the end of 2013/14 that can be reinvested in the service to continue to deliver year on year quality improvements.” The booklet placed emphasis on improving quality while reducing overall costs through strategies such as early intervention, improved infection control and home-based care. Its authors included Jim Easton, then National Director for Improvement and Efficiency. The DH described a series of QIPP ‘workstreams’ it was setting up to help clinical teams and NHS organisations “improve quality and productivity across care pathways”. The first of these related to care of long-term conditions, urgent care and end-of-life care. Further workstreams would examine safety challenges, such as pressure ulcers (bedsores), and ‘right care’ issues such as referral management and identifying “low-value treatments” (later to become controversial issues).

The authors called for “a collective response at local, regional and national level” to address the QIPP priorities. These included early diagnosis, primary and secondary prevention and patient self-management. The need for “better partnerships between primary, community and secondary care to support people with long-term conditions” was emphasised. QIPP extended from the “daily clinical practice” of individual HCPs to “the wider care pathway”, the booklet said. Each SHA had its own QIPP lead and innovation lead, and was establishing an online regional ‘quality observatory’ and Innovation Fund to help clinical teams improve quality and productivity.

These ideas were illustrated by case studies where local NHS organisations had developed better and more affordable healthcare solutions. These included the use of an electronic system to ‘re-engineer’ blood transfusion, reducing waste and improving safety; and systematic guidance on antibiotic prescribing to reduce rates of C. difficile infection. These solutions all involved using teamwork and sharing information to make the best use of available resources.

The booklet ended on a warning note: “If we do not respond to this challenge there is a real risk that the need to cut costs will overtake our best intentions to improve care for our patients.” More than two years later, the crucial question is: has QIPP averted that outcome or brought it closer?

Innovation is ‘core activity’
In June 2012, Nicholson’s annual report claimed 2011/12 had been “a remarkable year” for the NHS. He highlighted the contribution of local initiatives to maintaining service quality while cutting costs. Austerity would dominate the NHS “for the foreseeable future”, he said. However, the innovation agenda promoted by the previous Government’s Office for Life Science and revived by the current Government in December 2011 would engage dynamically with that challenge: “Innovation has to... become the core activity of the NHS.”

His report went through the elements of QIPP, noting achievements in each area. Quality achievements highlighted included: in cancer care, the achievement of key treatment standards across all eight performance measures, as well as improved early detection figures; and in stroke care, better access to specialist stroke units and faster treatment of people with transient ischaemic attacks. Community-based asthma services in South East Essex were used as an example of a successful local initiative.

The brief section on innovation focused largely on the use of technologies in the community, including telehealth and home dialysis. The preventative care section emphasised the growing role of health visitors, and drew attention to the success of a national screening campaign for risk of venous thromboembolism (VTE) with prophylactic drug treatment given where needed.

In the productivity section, Nicholson noted QIPP savings of £5.8bn and praised the “modest reduction in activity levels” across the NHS – placing these in the context of the QIPP Long-term Condition Workstream, which aims to reduce unscheduled hospital admissions by 20%, reduce hospital stay length by 25%, and maximise the role of “supported care planning” in helping people to manage their own health. However, no reference was made to the rationing of procedures or the cuts in hospital nurse staffing.

Milestones or millstones?
A recent Health Service Journal report on the DH’s QIPP tracker indicates that the PCTs (soon to be abolished) plan savings worth £13bn nationwide between now and 2015, with £4.5bn of this to be achieved through the 53 local QIPP plans. The planned savings are front-loaded: £3.8bn this year and £3.6bn, £2.9bn and £2.6bn in the next three years. However, only £2bn of the planned QIPP savings are currently being achieved on schedule, and only six local QIPP plans are on track with all of their workstreams.

According to the tracker, productivity gains are the main objective of most local initiatives. Common features include the redesign of care pathways for long-term conditions, including diabetes and COPD, and the development of integrated care teams for dementia patients. However, many local plans have the single goal of reducing the cost of services – for example, South of Tyne and Wear PCT notes as an objective: “reduce price paid for Gateshead Health Foundation Trust older people’s mental health service”.

John Appleby, chief economist of the King’s Fund, commented that this emphasis on savings denied the original point of QIPP: “to improve value to patients”. He also said there was no evidence of the money saved being reinvested in future services, which was a key principle of the original QIPP agenda. The Audit Commission has since reported that the NHS has £4bn in “uncommitted finances”: cash reserves created by aggressive cost-cutting. Mike Farrar, Chief Executive of the NHS Confederation, has argued that this money needs to be invested in community and primary care.

Jim Easton, the NHS Commissioning Board’s Director of Improvement and Transformation, warned in July that too many NHS organisations were relying on spending cuts without any element of service redesign. The “deeper change” of shifting healthcare to the community was not being undertaken, he said, and
QIPP was becoming a “label” for “cost improvement plans”. As a result, the QIPP savings of the past year would be very difficult to repeat. Instead of building a new healthcare model, the NHS was just cutting
parts of the old one.

Easton has since announced that the Board will fund a new innovation body to deliver a “system-wide” response to the QIPP challenge. From April 2013, the new organisation will replace all existing NHS innovation and technology adoption bodies. He anticipates that it will “provide hands-on support for great models of care” developed within and beyond the healthcare sector. However, his resignation has cast a shadow over these plans.

According to the King’s Fund, 27 of 42 NHS finance directors it surveyed believe there is a high risk that the NHS will fail to meet the ‘Nicholson challenge’. A key question for industry, and for patients, is whether QIPP can help the NHS deliver on the more important challenge of transforming healthcare to meet the
changing needs of the population.

BMA representative Dr Laurence Buckman has voiced his opposition to the rationing of NHS services.

Dr Buckman, Chairman of the Association’s General Practitioners Committee, has written to the General Medical Council (GMC) proposing that quality premium payments and the rationing of care be stopped.

In the letter Dr Buckman said the BMA “think this is appallingly unethical”.

The BMA chair asked the GMC to investigate these “incentive schemes” after CCGs and PCTs had ignored warnings by the Association to end the practices.

“Taking money from patient care and pocketing it for reducing something you do for patients by a fixed percentage or number is wrong,” he said in the letter. “We have said that repeatedly. We don’t think it is a good idea to tell doctors that if you reduce your referrals by 10% you will receive a payment.

“Although you might be mindful of expenses, you should not be chopping an arbitrary piece of patient service and then taking money which you are allowed to keep. There are lots of reasons why that is bad including the fact that patients will not trust you because they will think that everything you do will be dependent on making a profit out of it, from them.”

Dr Buckman’s letter follows a survey by Pulse Magazine which revealed that doctors believed the rationing of minor treatment services was affecting their relationship with patients.

NHS rationing is affecting the relationship between doctors and their patients, a new survey has found.

The survey by Pulse Magazine revealed that three quarters of GPs believe the doctor-patient relationship has been tainted by cut backs to certain treatments.

Dr Clare Gerada, Royal College of General Practitioners, said the problems of the Health and Social Care Act have resulted in patients holding GPs responsible.

Typical treatments which have been affected by a rationing include GP referrals for bariatric, hip and knee and cataract surgery.

Out of the 237 doctors questioned, nine out of 10 reported pressure to ration treatments or services over the past twelve months. Two-thirds of respondents admitted local rationing was adversely affecting standards of patient care.

More than 40% of doctors said they had changed the therapy of patients to less effective options due to rationing guidelines in the past twelve months. A third also raised issues with getting patients to guideline-directed targets.

GPs also exposed other forms of rationing with 89% finding patients had been referred back to them after missed hospital appointments and 31% claimed hospitals were overemphasising the risks of surgery in an attempt to off put individuals.

A spokesperson for the Department of Health said they would be writing to the NHS to remind them that rationing on the grounds of cost was wrong.

The NHS reforms are systematically taking power away from GPs and services away from patients, according to the new BMA Chair of Council.

Mark Porter, in a Guardian interview, has reasserted and updated the opposition of UK doctors to the Health and Social Care Act.

He pointed to the rationing and outsourcing of NHS services as evidence that the reform process is reducing “the NHS offer” year on year.

A major part of his argument related to the use of referral management centres and financial incentives to make GPs cut their referral rates. He said the former was “particularly distressing for GPs” who found their ability to meet patients’ needs “more constrained than ever before”.

Porter argued that GPs being offered money to cut their referral rates – for example, Harrow PCT has offered local GP surgeries up to £4 extra per patient if they “optimise the use of outpatient appointments” – is “morally wrong and professionally wrong”, since it creates a conflict of interests.

He also claimed that the rationing of procedures, which the Government has condemned, is an inevitable effect of austerity measures – and is leading to “the NHS offer” being systematically reduced.

Far from being banned through recent DH measures, he argued, NHS rationing is set to become “service-wide” within a few years.

In addition, he said, the new rule (operative from 1 October) that hospitals can reserve up to 49% of beds for private patients risks neglecting NHS patient safety.

The DH responded: “The NHS is treating more people and we are increasing the NHS budget in real terms.” It pointed to the QIPP savings of £5.8bn in 2011–12 as proving that the service “can meet the financial challenge set”.

The NHS will shortly launch an Innovation Scorecard system to highlight uptake of NICE-approved treatments by local NHS organisations.

The Department of Health also plans to combat ‘postcode prescribing’ through the automatic addition of approved treatments to local formularies.

Supporting these changes, a new advisory group will help local NHS organisations to implement NICE guidance.

The new measures, to be implemented this autumn, aim to reduce variation in patient access to medicines and other treatments assessed by NICE as cost-effective and clinically beneficial.

According to NICE Chief Executive Sir Andrew Dillon (pictured), the Innovation Scorecard will initially feature about 20 treatments where NHS uptake is known to be variable. Over time, it will cover all therapies approved by NICE.

“This is a step change in the detail with which we will be able to see how trusts respond to our recommendations,” he said, noting that the scorecard would be a “benchmark” for doctors as well as patients. Its launch is expected in September.

A new system will add NICE-approved treatments automatically to local formularies – thus preventing what NICE Chairman Sir Michael Rawlins called the “delaying tactics” used by local formulary committees.

To assist the change in prescribing culture, a new group will assist local NHS organisations in rapid compliance with NICE guidance. It will require adequate explanations from any trust or CCG that fails to comply.

Health Minister Paul Burstow described the “new regime” as “a catalyst for change”. Its transparency was “the hallmark of a 21^st-century NHS,” he said.

However, the impact of these changes in a time of continuing austerity measures has provoked concern. David Stout, Deputy Chief Executive of the NHS Confederation, commented: “In a health system with no financial growth, any new costs have to be offset by savings elsewhere."

Sir Michael Rawlins wants campaigners to take legal action against trusts that deny patients access to NICE-recommended drugs. Maxine Vaccine asks whether this is a powerful strike against bureaucracy or a pointless fit of sulking.

It’s not easy being NICE. When you decide a drug is not cost-effective, the manufacturer contacts a bunch of patient groups on Facebook and passes on soundbites to the press that make you out to be the most heartless despot since King Herod. When you decide a drug is cost-effective, the NHS quietly ignores you.

The Government says it will force trusts to make NICE-approved treatments available to patients – but at the same time, the recession comes back for whatever it forgot to wreck the first time, and the NHS is told it has to make deep spending cuts for the foreseeable future. Andrew Lansley first praises the NHS for hacking nearly £6 billion from its budget, then says rationing of NHS treatments is “unacceptable”. Simon Burns tells Radio Five Live that Monitor will sack CCG leaders who ration services, then the DH shamefacedly explains that he meant to say the Commissioning Board would do that.

And just to make matters worse, if you’re Sir Michael Rawlins, people confuse you with Sir Andrew Dillon and vice versa. Is it your fault that you both look exactly like 1970s newsreaders? Having good taste in neckwear wasn’t part of your job description. And you both have something of the knight about you. It’s time you stood up for yourself.

At least, that’s my rationalisation of why Rawlins went on the HSJ website and revealed that he encouraged the RNIB to take legal action against the NHS. I could be wrong, however. He may have had a touch of the sun, or a bout of lansley that his GP wasn’t allowed to prescribe for.

Whatever the reasons, his blog was in the awesome NICE tradition of standing on the moral high ground and waxing ironic over those below. He recommended that patient groups should use legal measures to “blow the whistle” on trusts that use “delaying tactics” to save money – thereby forcing them to put in place “appropriate financial arrangements” for the drugs in question to be provided. Then came his parting shot: “That would be a much better use of the time of formulary committees than trying to pretend they have the knowledge and skills of a NICE appraisal committee.”

Strangely enough, that didn’t go down too well with the NHS. David Stout, Chief Executive of the NHS Confederation, responded with an air of wounded dignity: “We must remember the reality is that every NHS organisation has a finite amount of money available. Every new treatment covered and funded under a NICE technology appraisal means fewer resources for other treatments.

“The issue raised by Sir Michael Rawlins leads us on to the wider debate that we need to have about the fact that the NHS is facing an unprecedented financial challenge,” he continued. “We need to be open and honest with the public about what the consequences of this financial challenge are, and the fact that trade-offs will be required if we are to improve standards of care while keeping the NHS affordable.”

That is rather good – and it cuts through the DH’s excuses like a scalpel through the contents of an inflamed colorectal tract. We need a public debate about NHS rationing – its economics, its democratic basis, its medical and social impact – not confused denials that such activity was ever dreamt of. If it was Rawlins’ intention to force that debate into the public space, he did well.

Bring it on.

Maxine’s views are not necessarily those of Pharmaceutical Field.

The rationing of NHS services has become a focus of political debate, though all politicians involved have condemned it.

A Shadow Health Minister has called for “an immediate review” of rationing and action on clinically unjustified decisions.

Health Minister Simon Burns has said that CCG leaders may be sacked if they fail to correct cost-driven restrictions on care.

In June, a study published by GP magazine revealed that 91% of PCTs impose limits on referrals for ‘non-urgent’ procedures such as cataract surgery and hip and knee replacements.

Clinicians have argued that these procedures, when delayed, become both more urgent and more costly, while patient wellbeing suffers.

Following a Parliamentary debate on this issue, Health Secretary Andrew Lansley insisted that “blanket plans on treatments” are “unacceptable”.

He argued that the new CCG structure would give GPs more power to resist rationing, because they would no longer be dictated to by PCTs.

Simon Burns told radio listeners that PCT leaders could be dismissed by the DH if they failed to restore clinically necessary services. In future, he added, Monitor could exert the same sanction on CCG leaders.

The DH subsequently clarified that the NHS Commissioning Board, not Monitor, would have that power.

Shadow Health Minister Lord Hunt of King’s Heath (pictured) called online for “an immediate review of rationing in the NHS”, with action to reverse “treatment restrictions” that caused suffering or restricted independence.

The decision whether to make a treatment available should be made at a national level, he argued, rather than locally and “in a random fashion”.

As Chair of Heart of England NHS Foundation Trust, Lord Hunt has stated that ‘efficiency savings’ should not affect the quality of NHS services.