In Part III of his diary, Omar Ali discusses the significance of process mapping and the wide reaching influence of health technology assessments and regulatory bodies.

1.10pm: GP CONSORTIA/CCG – RESPIRATORY ASTHMA PROCESS MAPPING & FORMULARY

I’m trying to step into the main meeting room but one of the CCG/GPs pulls me aside. It’s a mixture of a low-key signal and a discreet ‘thumbing’ to pull away from the group. He wants a quiet word and it’s clear that there are some key issues, agendas and directions that are on the table for this asthma meeting.

The process mapping event takes some four hours – evaluating everything and anything that ‘leads to an asthma admission’, followed by everything and anything that occurs after the admission and leads to discharge – which is then followed by QIPP ‘bottlenecks’, where re-admissions and inefficiencies occur.

It’s always a challenge having so many viewpoints – nurses, physicians, pharmacists, budget holders, and of course patients and carers who often change the whole paradigm when we hear about their experience, expectations and concerns around ‘choice’.

Thoughts for pharma

Respiratory is big. Whether on prescribing budgets, healthcare priorities, implementation of national guidance or QIPP streamlines. Companies haven’t yet got their act together on process mapping of care pathways, but it’s the only way to invest in prescribing up-front drugs for potential ‘return to the QIPP baseline’ over the next three to five years. Needless to say, whilst the NHS talks QIPP, pharma is getting used to it and patients are still puzzled by it.

Asthma

With so much behind National Guidance/BTS, QoF and commissioning cycles, some companies are indeed getting into the mix with Clinical Commissioning Groups and supporting process mapping. That support is vital, as not only does it bring pharma in as key stakeholders, but more importantly there is a level playing field here in the same room bringing the cause back on track.

So often in the NHS we have silo budgets chasing after silo savings. Process mapping brings us out of our silos into the bigger picture and into the ‘process map’. Seeing it happen is a wonderful thing.

COPD

Given we make such a fuss around the cost of drugs, in truth we know two things: the most expensive drug is the one that is not being taken, and the tariff for an admission for COPD at £3,400 is more expensive than the annual price of the most expensive inhaler!

So where’s the issue? It goes like this. Pharmaceutical companies come to us quoting the costs of admissions in COPD then tell us how amazing it would be to reduce these hospitalisations.

They then tell us how amazing their COPD product is and tell us that we would be crazy to not buy their inhaler, which is a fraction of the cost of COPD burden/admissions. The GPs, nurses and patients love it and want it and state they ‘need it’. Medicines Management then look like the bad guys for not funding the said branded inhaler.

4.15pm: DRIVING BACK TO NHS BASE CAMP – CHECKING VOICEMAILS

One of the big five companies has asked me to come and present to their European heads-of-country on ‘payer issues’ in the UK and the influence of HTAs.

It’s a bit short notice and I gather the VP for Europe, Middle-East and Asia will be there. Times are tough and I see this as an example of how the EU can join forces on some of the key payer issues beginning to filter through.

I have one question back to these pharma companies. What is your data on reducing these expensive hospitalisations in COPD? Because in truth, with the data, I buy the story.

In most cases pharma will then spin another story around how compliance is great, or a patient support programme is excellent. But given all the spin that has come on how much COPD costs me in hospitalisations, it’s a shame many of the companies don’t have the evidence to help me.

They have marketing but not the evidence. Show me the money. And the formulary will be yours.

Thoughts for pharma

There is no doubt that the UK is ‘different’, but I don’t imagine global HQ for any of the pharmaceutical companies readily accepting that – especially when the targets are high and sales may not be so. It sometimes takes global agencies to hear about payer issues ‘from the horse’s mouth’.

This was the quote stated to me regarding this piece of work/event. From my work abroad – at NICE I informally interact with a number of contacts in other countries who belong to their residing equivalents – I can’t stress enough the importance of NICE, the SMC and similar bodies.

The last SMC decision on pain management was quoted verbatim within two weeks by three different countries within the EU. I’m also aware from my US/value-based pricing work that when NICE rules on a drug the impact on the US healthcare system is far reaching.

Insurance companies download the information – they can’t believe NICE do all this work transparently and then leave it freely available for anyone to download – and the US agencies then use this information on deciding what percentage they will ask patients to pay.

So, if NICE say no and SMC say no, somewhere a butterfly flaps its wings and then a patient in the US, who has paid extra funds into a private insurance policy, will be told that this particular brand is not covered and that the patient will have to make an additional payment if they want the drug.

To be continued...

Omar Ali is the Formulary Development Pharmacist for Surrey & Sussex Healthcare NHS Trust and sits on the External Reference Group for Cost Impact Modelling for NICE. He may be reached on omar.ali@sash.nhs.uk.

Health Secretary Andrew Lansley claims the Government has “fought together” in its efforts to introduce its proposals set out in the Health and Social Care Bill.

Speaking to delegates at the Conservative Party Conference, the Health Secretary says he has battled against criticism from Labour and left-wing unions who have misunderstood his plans.

Mr Lansley said there had been “misinterpretation, misinformation and misrepresentation” about the Bill but the reforms remain “the right thing to do” for a better NHS.

He admitted that brining change has “not been easy” and the Government has always been“absolutely clear” over its plans.

“We are committed to the values of the NHS,” the Health Secretary said. “To a comprehensive, high-quality service for all, free at the point of use and based on need, not ability to pay. The Health Bill will safeguard those values.”

The Bill will also “improve quality, reduce health inequalities, empower patients and staff, improve local accountability and strengthen public health services”, he added.

The Health Secretary said to “reassure people” that the Bill is right for patients and the NHS, the Government consulted “the country’s top experts”, the NHS Future Forum, to address concerns and offer their recommendations. He said that amendments have now been made “so that competition is on quality, not price; to ensure the continuity of services for patients; to support education and training; and to strengthen integrated care”.

He ended his address by outlining his and the Prime Minister’s commitment to the NHS. “While I am Secretary of State, the NHS will never be fragmented, privatised or undermined. I am personally committed to an NHS which gives equal access, and excellent care.”

The NHS reforms have faced a continual wall of criticism, its most recent from the BMA, which said that the Bill “poses an unacceptably high risk to the NHS in England”.

The ABPI has warned a complete switch from the current Pharmaceutical Price Regulation Scheme (PPRS) to a value-based pricing (VBP) approach may not halt a lack of UK innovation.

Britain’s pharmaceutical trade body is instead proposing the introduction of various aspects of VBP into the current system in favour of a complete overhaul.

Stephen Whitehead, Chief Executive, ABPI, said in an interview with The Telegraph that VBP “doesn't actually seem to do anything to encourage innovation”.

Governments in Spain, Greece, Italy and most recently Germany have introduced similar schemes in an attempt to save money with drugs priced according to their benefits to patients.

The existing PPRS ends in 2014 with the Coalition Government proposing a switch to VBP. The existing scheme regulates profits pharma companies can generate but does not decide individual prices.

Mr Whitehead welcomes the introduction of certain aspect of the new scheme, such as the societal benefits a new product may have, but believes an integrated approach would be more beneficial.

“We would like there to be a single holistic scheme that is low on bureaucracy, efficient, patient-focused and reflects an element of freedom of pricing which we have with the PPRS because it’s profit controlled,” he said.

A spokesperson for the DH defended the planned introduction of VPB saying: “We need a much closer link between the price the NHS pays and the value that a new medicine deliver.”

Eli Lilly CEO John Lechleiter recently campaigned to the German government that a switch to VBP there would ultimately discourage investment and innovation from the pharmaceutical industry.

Protests are being planned ahead of the Health and Social Care Bill’s passage through Parliament next week.

UNISON and the BMA are planning to show their opposition to the controversial reforms to coincide with report stage and third reading of the Bill on the 6th and 7th September.

Local events nationwide are planned to coincide with Bill entering the House of Commons with NHS staff and patients set to gather for a candlelit vigil outside Parliament. The BMA is also urging campaigners to take part in online action to email their MP signalling their opposition, and to use Twitter and Facebook to voice their concerns.

BMA Council Chairman, Dr Hamish Meldrum, has also written to all MPs saying the reforms still present an “unacceptably high risk to the NHS” warning them it threatens its ability to operate “effectively and equitably, now and in the future”.

Despite the amendments following recommendations from the NHS Future Forum, the Association still believes the Bill should be withdrawn or be subject to further substantial changes.

In his letter, Dr Meldrum continues to warn of the “inappropriate and misguided reliance on ‘market forces’ to shape services” with the Bill creating “a more central role for choice without a full consideration of the consequences” and the “potential to destabilise local health economies”.

There are several specific areas of concern the BMA has on the Bill including:

• The limit Foundation Trusts (FTs) can generate from private patients
• The proposed ‘Quality Premium’ for commissioners
• Forcing all NHS Trusts to become FTs
• That the Bill reflects an intention that any increase in patients’ choice of providers should not be given a higher priority than tackling health inequalities and promoting integrated care
• Ensuring there is a robust and transparent process which has the full confidence of the profession when it comes to how ‘failing’ FTs are dealt with
• The lack of satisfactory assurance that the Secretary of State will have ultimate responsibility for the provision of a comprehensive health service whilst also allowing other bodies, like the new NHS Board and Clinical Commissioning Groups, day-to-day operational independence.

In a response to the concerns over the responsibility of the Secretary of State, the DH says “the Secretary of State will continue to be responsible - as now - for promoting a comprehensive health service. The NHS will always be available to all, free at the point of use and based on need and not on the ability to pay. To say otherwise is absolute nonsense”.