VPAS: Progress two years in and opportunities to improve over next three years
In the final instalment of our series reviewing the the 2019 Voluntary Scheme for Branded Medicines Pricing and Access (VPAS), Leela Barham takes stock of the whole scheme after digging more deeply into its three objectives.
The VPAS has set out objectives in three areas; for patients, for affordability and for the economy and innovation. The DHSC has simplified these objectives in their first report on metrics in the scheme, published in July 2020, as:
- For patients: simplify, streamline and improve access, pricing, and uptake arrangements for cost effective medicines, and deliver faster adoption of most clinically and cost effective medicines
- For affordability: contribute to maintaining affordability of Branded Medicines spend, and provide predictability for all parties to enable certainty of planning for NHS and industry
- For the economy and innovation: deliver a net benefit to the UK economy overall and support the life sciences industry across the UK and future innovation.
The challenge is trying to unpick just what these really mean. For example, just what is a simplification that is not also some form of streamlining? Affordability too is interpreted narrowly in the scheme with an allowable growth rate in total NHS spending on branded medicines set at 2%. Predictability is always going to feel like an oxymoron for a scheme that inherently allows for changes in payments reflecting changes in the market; the predictability is for the government but not for industry.
A net benefit to the UK economy is not meaningfully defined and support for the life sciences industry and innovation is something that can’t be delivered alone by the VPAS; there is more than pricing and access which matter to the life sciences industry. Industrial policy is a missing – at least in the VPAS alone – but a vital part of supporting industry. It’s why it’s a mistake just to focus on the VPAS and why discussion should take in efforts such as the Life Sciences Sector Deal and other initiatives that are housed in other government departments.
The lack of specificity of the objectives is at odds with much of the rest of the VPAS which at times reads just like a contract, despite not being one. It makes for an agreement which is neither a legal document nor a policy one. That’s not a criticism; rather it’s an inevitable outcome of writing by committee and with authors being both lawyers and policy people as well as other experts. There is an opportunity however, in the next three years, to bring clarity in how the VPAS is assessed. There are also lessons to learn for drafting a successor scheme for 2024 onwards; policy focused and shorter could be aims next time around.
An opportunity to supplement current metrics to assess the VPAS
That there is a need for subjective interpretation of the goals of the VPAS is not necessarily an inherent problem for a voluntary agreement, but it does make it hard to assess progress and determine whether stakeholders are getting what they hoped for. It is why there have been development of metrics to assess progress, but the first metrics report from July 2020 is narrow in what it covers. It includes:
- Product launches – price applications
- Number of Single Technology Appraisal (STA) by NICE and the percentage that were positive as well as classification by type of recommendation for all STAs and STAs of New and the speed of appraisals both for the first output, and the final output
- Scheme membership and share of the market
- Overall sales and sales by scheme (which includes the statutory scheme)
- Exempt sales and sales of small and medium companies
- Growth gross of payment
These metrics are largely operational; pragmatic yes, comprehensive, definitely not. The best interpretation is that the scheme can work in practice and that elements of the scheme that relate to the work of others – NICE in this case – can be reported on.
More positive is that the VPAS has proven to be more attractive to companies than the statutory scheme (although that is not necessarily a ringing endorsement of the attractiveness of the VPAS, it’s essentially choosing the least-worst option). 192 companies were members of the VPAS in 2019 versus 175 in the previous deal, the 2014 Pharmaceutical Price Regulation Scheme (PPRS). That led to coverage of the total market to hit 92%, a rise on the 80% covered by the PPRS before.
There is however, a great deal missing when you consider the metrics versus the scope of the deal; to get a sense of progress you have to go further and look more widely. The DHSC and ABPI would do well to ensure that easily available metrics, such as the Office of Life Sciences life sciences competitiveness indicators are part of their operational reviews to help bring a wider view of how well the UK is supporting the industry and innovation. Perhaps it’s a casualty of COVID-19 or Brexit but OLS have yet to publish the 2020 indicators, at the time of writing.
The real goal: getting more bang for the buck but no metric to assess this
The VPAS may have stated objectives, but it also has discussion of the purpose of the scheme. That makes it clear that the goal was to “engender improvements over time to health gain relative to expenditure on new medicines across the NHS”.
What that means is that the system is geared to get better value for money on individual treatments, even if cost-effective and affordable already and within an overarching scheme that guarantees affordability for the NHS.
This should translate to needing a more meaningful metric – but one that is getting harder and harder to get public access to – such as the cost per Quality Adjusted Life Years (QALYs) that are being secured for treatments. Whilst that might be available through appraisals by NICE, the real numbers are often hidden to the public due to confidential commercial arrangements struck between companies and NICE and NHSE&I.
An opportunity to increase transparency
A common theme when assessing progress against the objectives of the VPAS is the lack of public information. It may well be known how some of the commitments, such as enhancing horizon scanning, improving engagement, increasing flexibility as just some of them, are being met by those working at DHSC, NHSE&I and for those working at the ABPI and within companies.
Yet the scheme has explicitly cited the benefits for patients and through the objectives to support the life sciences industry and deliver a net benefit for the UK economy and support innovation, it also has goals for UK citizens more generally. Yet there is little for an interested patient or citizen to draw upon beyond regular data on payments, the payment percentage and meeting minutes from the operational review. Even those interested in digging deeper themselves (like this author) get stumped by websites that are uninformative or no longer up to date.
In the old days of the PPRS there were annual reports to Parliament (the last one found dates from 2014). They helped shine a light on what the scheme had achieved and offered some important context, such as progress on support for the industry. If memory serves they came about because of a lack of transparency surrounding the very early iterations of VPAS.
Annual reports also presumably provided a one stop shop to help parliamentarians in understanding the situation. Then there is also the argument that there will be many in other countries who are interested; be they lawmakers, policy makers, industry or anyone else such as academics. Could an equivalent come back? It would be extra work, but it’s likely to help provide material that will help those who negotiate a future deal, as well as provide assurance to those outsiders with an interest in the progress and success of the VPAS.
A deal that definitely delivers for government
Whilst it’s too early to draw conclusions on the success or otherwise of the VPAS, as it has three years left to go, it is clear that so far it’s the government that is definitively reaping the benefits. There is a long way to go to not only deliver on some of the commitments on access, but even further to evidence that they have generated the hoped-for improved patient outcomes and market access outcomes that matter to companies and patients. All parties should be working together to take a balanced view to assess delivery of the Schemes ambitions and to help inform future deals. Time for a VPAS balanced scorecard?
To view the rest of the articles in this series assessing the progress of the VPAS, click here.
About the author
Leela Barham is a researcher and writer who has worked with all stakeholders across the health care system, both in the UK and internationally, on the economics of the pharmaceutical industry. Leela worked as an advisor to the Department of Health and Social Care on the 2019 Voluntary Scheme for Branded Medicines Pricing and Access (VPAS).