22 September 2017
Plans to cut NHS costs by blocking the ability of doctors to prescribe thousands of ‘low-value’ treatments for patients are causing controversy.
NHS finances are a constant source of concern. Just a few months ago, the House of Lords Long-term Sustainability of the NHS Committee noted that the financial performance of NHS bodies had ‘worsened considerably’ and concluded that the reduction in health spending as a share of GDP seen over the last decade cannot continue beyond 2020 without seriously affecting the quality of, and access to, NHS care.
While the NHS has been promised additional funding, the government has since confirmed that the NHS budget per person will drop in real terms by 0.6% in 2018/19. Meanwhile, the NHS is expected to find at least £22bn in efficiency savings by 2020 – a mammoth task with no clear direction as to how this is to be achieved. While the Carter Review offered a potential starting point by highlighting vast differences in procurement costs between hospitals, a recent report found that ‘huge differences’ in the prices of surgical products persist after more than two years. Another area that has come under scrutiny is prescription costs. Last year 1.1 billion prescription items were dispensed in primary care at a cost of £9.2 billon. Variations in what is being prescribed and to whom suggest there is room for improvements in order to ensure patients receive the right drugs at the right time. This would improve health outcomes and save the NHS money.
Variations in what is being prescribed and to whom suggest there is room for improvements
Prescriptions came to the fore as part of the fight against antimicrobial resistance (AMR), a growing and persistent threat to global health that carries a hefty price tag in addition to the potential loss of life. The World Bank has already warned that by 2050, drug-resistant infections could cause global economic damage on par with the 2008 financial crisis. The UK government has committed to combatting AMR through a range of measures including better stewardship (ie. more responsible, reduced prescribing) of antibiotics.
In a more recent attempt to save money, NHS officials announced plans for new national guidelines for Clinical Commissioning Groups intended to stop primary care providers from prescribing ‘low value’ overpriced or ineffective medicines. It is proposed that a total of eighteen treatments including homeopathy and herbal treatments should be stopped; a consultation on the plans is currently open for comment. NHS Chief Executive Simon Stevens said: "the public rightly expects that the NHS will use every pound wisely, and today we're taking practical action to free up funding to better spend on modern drugs and treatments". A separate consultation is already underway on proposals to stop the prescription of gluten-free products for allergy patients.
In addition to the detailed recommendations made with respect to the eighteen specific treatments or groups of treatments, the new guidance proposes restricting the prescription of more than 3,000 different products currently available over the counter (for sale in pharmacies or other outlets without a prescription), said to cost the NHS around £645 million a year - they estimate this could save over £190 million. These items include remedies such as cough mixture, cold medicines and laxatives.
The new guidance proposes restricting the prescription of more than 3,000 different products currently available over the counter...they estimate this could save over £190 million.
For some, the proposals are long overdue; whilst the UK multimillion pound homeopathy and herbal medicines industries may not be pleased, scientists and doctors have been highly critical of NHS funding treatments that consistently fail to demonstrate any evidence of utility beyond a placebo effect. The British Medical Association, the Royal Pharmaceutical Society and even the House of Commons Science and Technology Committee have all supported an end to the prescription of homeopathy in the NHS. There has been wide agreement that ‘homeopathy is based on implausible assumptions and the most reliable evidence fails to show that it works beyond a placebo effect’. However, other proposed cuts have been quite controversial.
Is the NHS abandoning the historic principles that care should be free at the point of access for all those who need it? Rather than basing NHS services on clinical need, charity National Voices has argued that this policy would introduce ‘ability to pay’ through the back door and disproportionately affect those with greater needs or lower incomes - perhaps the primary concern with the proposed cuts. While the average Briton may not feel the effects of paying for pain-killers, cold remedies or head lice treatments, a ban on over-the-counter medicines risks disadvantaging those who have come to depend on such prescriptions. Those barely managing would be faced with new financial and health challenges as they struggle to pay for basic pain relief and other essential treatments, or simply go without them.
More people getting sick and staying sick is surely not the goal of this new policy - but it is a potential consequence.
This approach could also backfire in financial terms. Forcing those less well-off to pay or go without their drugs risks facilitating a rise in demand for GP appointments, hospital visits and prescriptions for stronger drugs. By not taking the necessary drugs, the health service risks these patients presenting with worse conditions in the long term. More people getting sick and staying sick is surely not the goal of this new policy - but it is a potential consequence.
An alternative approach for savings on NHS treatment might be to limit not only prescriptions, but also costs. Professor Azeem Majeed raised this point, suggesting that the NHS could instead focus its attention on negotiating a better price for generic drugs from monopoly suppliers. The NHS is “very bad at tackling this”, he argued, giving the example of Tamoxifen, a breast cancer treatment, which he says cost just 10p a tablet in 2011 but rose to £1.21 last year. The effect of the Cancer Drugs Fund on costs further illustrates that the government certainly needs to better understand and address the cost and provision of drugs in the UK.
Ultimately, the need for cost-cutting is so great that reducing numbers of prescriptions as well as the costs of prescribed items to the NHS should probably be expected. How far the needs of the public, the NHS and industry can be balanced in this respect remains to be seen.