Crossed wires? Mixed messages on medicines

Leela Barham argues that the latest operational guidance for the NHS in England continues to illustrate a disconnect between the messages in big-ticket policy documents from the central government and the messages from the NHS in England on medicines. With a successor for the 2019 Voluntary Scheme for Branded Medicines Pricing and Access (VPAS) being negotiated and a refresh of the NHS Long-Term Plan being on the to-do list for 2023, there is a chance for more alignment.

Government priorities

In addition to legislation, the government sets out an annual Mandate to NHS England that provides the objectives and budgets for the health service in England in a given year. This makes clear just what is most important.

The 2022/2024 Mandate was published on 31st March 2022. Its five objectives are:

Continue to lead the NHS in managing the impact of COVID-19 on health and care;
Recover, and maintain delivery of, wider NHS services and functions;
Renew focus on delivering against the NHS Long-Term Plan (more on that below) and broader commitments for the NHS;
Embed a population health management approach within local systems; &
Ensure effective NHS leadership, culture, and use of organisational resources to realise the benefits from future structural changes within health and care.

Hard to see how these can be delivered without optimising the use of medicines, even if not explicitly name checked.

The Mandate to NHS England was published before the latest change in Prime Minister for the UK, with Rishi Sunak taking on the role in October 2022. And on 4th January 2023, he set out five priorities for the UK. One of those relates to the NHS: getting waiting lists to fall and for people to get the care they need more quickly.

The care that patients need could be – although not always, of course – the right medicine, at the right time.

That’s how and what the high-level objectives are for the NHS in England, but how does the government provide the messages for getting the right medicines researched and developed and ultimately into patients? For that, the government has set out the Life Sciences Vision, published back in July 2021.

The Vision included ambitions to make the UK the best place in the world to trial and test products at scale, making the NHS the country’s most powerful driver of innovation through the development, testing, and adoption of new tech at population scale and the creation of an outstanding business environment for life sciences companies. The latter included aligning incentives to support company growth, innovation, and investment.

NHS England priorities

There’s some translation between what government says it wants and what that means for the NHS, which is a reflection not only of practicalities – politicians tend to make easy promises that are hard to deliver on the ground – but also because the NHS in England has a degree of independence from the government, too.

NHS England has set out priorities in the past, particularly through the Long-Term Plan, which came out in January 2019 with elements within it taking a ten-year perspective. Five key areas in focus in that plan were:

Doing things differently, with people given more control over their own health and care, and integrated care from the NHS covering the community sector, too;
Preventing illness and tackling health inequalities;
Backing the workforce with training and recruitment;
Making better use of data and digital technologies, such as the NHS app; &
Getting the most out of taxpayers’ investment in the NHS, including using the NHS’ buyer power.

When it comes to medicines, they were in the plan as well, not only indirectly through priorities for diseases like cancer, but also directly mentioned. That includes reference to the Voluntary Scheme for Branded Medicines Pricing and Access (VPAS), a five-year deal struck between the government and the pharmaceutical industry in 2018 and running from 2019 to 2023. The Long-Term Plan pointed out how that scheme would “mean patients benefit from faster adoption of cutting-edge and best-value drugs.”

The Plan also highlighted the aim to achieve value from the £16 billion worth of spending on medicines through things like electronic prescribing systems to lower errors, as well as reduce the prescribing of low clinical value medicines and over-the-counter medicines.

The Long-Term Plan also gets interpreted in the form of yearly priorities. The 2023/24 priorities and operational planning guidance came out on 23rd December 2022. That set out three tasks:

Recover core services and productivity;
Make progress in delivering key ambitions in the Long-Term Plan; &
Continue transforming the NHS for the future.

These are shaped by the COVID-19 pandemic, which has put a spanner in the works for the ambitions set for the NHS back in 2019.

In the context of the use of resources, the 2023/24 guidance also has text that says, “Purchase medicines at the most effective price point.” The NHS can secure this by using the opportunities for price efficiency identified by the Commercial Medicines Unit. The guidance also states that, by doing so, the NHS will “ensure we get the best value from the medicines bill”.

Local NHS priorities

Because the NHS is not just NHS England, there is local interpretation of the Long-Term Plan, too. Forty-two Integrated Care Systems (ICSs) will all be working on their local strategies. They need to meet the national objectives from the 2023/24 guidance and the Long-Term Plan, as well as local priorities.

The ICS strategies are likely to be a work in progress for many, but the strategy needs to be signed off by the great and the good locally before the end of March 2023. For industry, the questions are if and how medicines might feature.

A disconnect between the centre and the NHS?

In theory, there should be a clear incentive for the NHS to make the best use of medicines. Especially those that have not only been given regulatory approval, but also been recommended, even if optimised for certain patients in certain circumstances, from the HTA body, NICE.

That’s because not only have they been shown to be clinically and cost-effective, but because the 2019 VPAS sees companies paying back when the branded medicines bill grows by more than 2% at the national level. In the final year of the current deal, paybacks are predicted to reach a high for any single year so far, at £3.3 billion, according to the ABPI. There’s also a statutory scheme that requires paybacks for any medicine not covered by VPAS, with some exceptions, such as low cost.

But what is the message that the NHS on the ground gets? Presumably, one is that the cost of medicines still needs to be managed and, arguably, tightly so. That might be a cynical interpretation of the 2023/24 guidance because it focuses on price and does not – and would not – cover volume. And there are very good reasons to optimise the use of medicines: whether they are theoretically ‘free’ or not, they should be used appropriately.

Money is also not the only – perhaps not even the biggest – challenge for the uptake of medicines.

There is no mention of VPAS in the 2023/24 guidance. That may be okay, but it’s at best missing out on a very important way in which prices that the NHS sees aren’t what the NHS, ultimately, pays. It’s hard to see the link between VPAS paybacks and what the NHS receives: the money goes from companies to the Department of Health and Social Care; from there, it goes to the NHS, split out across the devolved nations; the money then goes into the general pot to be spent on what the NHS in each country of the UK sees as best.

Yet, there could be a need to nuance the message. It’s about focusing efforts on getting clinically and cost-effective medicines into use, and even more so when those medicines can generate the efficiencies that the NHS is being asked to deliver. Those messages were in the Long-Term Plan.

The Long-Term Plan highlighted, for example, how 90% of NHS spend on asthma is on medicines, but that incorrect use can lead to poorer health outcomes and increased risk of exacerbations, or even hospital admission.

But that nuanced message – about the value of medicines to help the NHS deal with the very things that are a priority now - might not be being heard or acted on, for whatever reason. Indeed, IQVIA analysis has found that NICE-approved medicines can take four years to reach the expected uptake.

Opportunity through the successor to VPAS and a refreshed Long-Term Plan

That there is a misalignment in the policy messages on medicines is not news. It’s a well-known problem. Unravelling both explicit and implicit incentives in how the NHS is managed that affect how the cost, price, and value of medicines are perceived and how they are used is not easy. It would help just to get the messages aligned.

If there is an issue with incentives for uptake of NICE-approved medicines, there may also be a case to make a much clearer link between VPAS monies – should a successor stick to capping NHS spending through company paybacks – and uptake at a local level in the NHS. At the very least, ICSs should know just what their portion of VPAS paybacks are.

Although quite what linking VPAS monies and uptake of NICE-approved medicines could – or should – look like needs much more thought (answers on a postcard please!). Money alone is unlikely to work though; much more than that is likely to be needed to achieve faster uptake of NICE-approved medicines.

There are opportunities in 2023. Both VPAS and the Long-Term Plan are getting a refresh and could therefore become more aligned, at least in their messages on medicines. On the money side, all stakeholders need to get their thinking caps on!

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).