UK market access and the patient perspective

Kate Morgan from Myeloma UK discusses market access in the UK. She sets out what patients want and expect from their treatment, the challenges and barriers they have in accessing treatments in the UK as well as a number of potential policy solutions.

Introduction

Market access is an important concept and one that is increasingly fashionable. On a basic level, it refers to the environment in which pharmaceutical companies bring new products to market.

From the perspective of patients, it is important that the market access system in the UK is efficient, balances demand and supply and results in patients getting timely access to treatments their clinician's consider the best for their disease and their individual preferences.

This article sets out what patients want and expect from their treatment, the challenges and barriers they have in accessing treatments in the UK as well as a number of potential policy solutions.

What patients want

Patients rightly expect to be able to access the innovative treatments that their clinicians prescribe them on the NHS.

In myeloma, a complex and incurable bone marrow cancer, an innovative treatment may constitute one that prolongs a patient's overall survival with a limited impact on their quality of life and one that reduces the complications associated with the cancer. Patients also want to be able to access treatments that have limited side effects and that offer convenience or the ability to continue with normal everyday activities.

Preferences for treatment differ depending on the individual patient. For example, patients may enjoy the interaction that receiving a treatment in an outpatient's clinic brings, whereas others may enjoy the ability to receive their treatment in the home.

"Patients rightly expect to be able to access the innovative treatments that their clinicians prescribe them on the NHS."

Market access is therefore very important in ensuring that patients are able to receive treatments that adhere to their needs and expectations. However, from our experience, we know there are significant challenges and barriers preventing this from happening.

Market access: challenges and barriers

A major market access challenge for cancers like myeloma is the lack of strategically designed clinical pathways.

Health technology assessment (HTA), undertaken by bodies such as the National Institute for Health and Care Excellence (NICE), is designed to assess the value that a treatment offers to the NHS in terms of clinical and cost-effectiveness.

In myeloma, whilst HTA has allowed patients to access novel treatments such as Velcade® and Revlimid® on the NHS; this has only been for specific phases in the treatment pathway – Velcade at first relapse and Revlimid at second.

As myeloma is a complex and heterogeneous cancer it is important clinicians have a range of treatment options available to them, and that they are able to use these treatments in flexible ways to treat the needs of individual patients. The current system of market access does not allow for this, particularly as commissioning bodies tend to implement HTA guidance to the exact word – encouraged by schemes such as the Innovation Scorecard.

Over the years, there have been a number of high-profile negative decisions from the UK HTA bodies. Whilst it is easy to pinpoint the flaws in the HTA decision-making processes and methodology, it is clear that the pharmaceutical industry need to take their share of responsibility for negative HTA decisions.

We know that the evidence of clinical effectiveness supplied by the submitting pharmaceutical company does not always adequately justify the high prices they have set for their treatment, particularly where the treatment may only offer a marginal additional benefit compared to current practice.

"Market access is therefore very important in ensuring that patients are able to receive treatments that adhere to their needs and expectations."

In addition to this, the large licensing trials submitted as evidence to HTA tend to use comparators that do not factor in standard NHS clinical practice, making it difficult to assess how the new treatment will improve care for NHS patients.

The existence of and need for 'stop-gap' measures such as the Cancer Drugs Fund in England is testament to the fact that long-term, sustainable improvements need to be made to the system of market access in the UK.

Stakeholder interests

In order to address the problems in market access, you have to assess the motivations and drivers of different stakeholders. Patient treatment and choice may be the stated end-goal of market access, but many other factors are at play.

Market access impacts on the investment decisions and company models of the pharmaceutical industry and on how they guarantee a return on investment from products. The Government also needs to ensure continued pharmaceutical investment in the UK whilst at the same time demanding value-for-money from the pharmaceutical industry.

It is the needs and preferences of these stakeholder groups, as well as patients, and the need to find a balance between them that has a major impact on the market access environment in the UK.

"...it is clear that the pharmaceutical industry need to take their share of responsibility for negative HTA decisions."

Solutions and current policy

The balance of the market access system in the UK is gradually shifting as the Government has begun to push back to the pharmaceutical industry over issues such as pricing.

The announcement of value-based pricing (VBP) is a major indication of a demand from the pharmaceutical industry to do better job of justifying the prices they charge for their medicines, although on its own VBP is not going to solve the problems with market access.
Stakeholders need to come together to agree what would constitute appropriate evidence of a treatment for HTA and do a better job of producing that evidence. We also need more transparent approaches to pricing and sophisticated ways to assess value to ensure that the price paid is fair to all stakeholders.

We also need to think about other levers for increasing access and uptake of new medicines. This could be through initiatives such as better commissioning incentives to encourage uptake of new medicines or developing and commissioning clinically relevant and costed pathways of treatment for diseases, rather than looking at each stage of the disease in isolation during HTA.

"Stakeholders need to come together to agree what would constitute appropriate evidence of a treatment for HTA and do a better job of producing that evidence."

The recent commissioning reforms to the NHS through the Health and Social Care Reform Act 2012 offer some opportunities in this respect, as there is currently a movement towards commissioning pathways of treatment through NHS England. However, as there are still a number of organisational issues that need to be addressed, it is yet unclear whether these opportunities will be realised.

Conclusion

Moving forward, it is clear that a comprehensive suite of policy initiatives is needed to ensure that all stakeholders benefit from an efficient and fair market access environment in the UK.

It is also anticipated that market access will endure another marked shift in coming years. It is important that stakeholders look down the line towards an era of increasingly personalised medicines and consider the opportunities and challenges this brings to improve market access and patient outcomes in the NHS.

About the author:

Kate Morgan is Policy and Campaigns lead at Myeloma UK, with responsibility for the charity's policy work and engagement with UK policy makers on a range of issues from market access and pricing through to patient access to information and support in the NHS.
Myeloma UK is a charity that helps to improve treatment and standards of care for myeloma patients through research, education, campaigning and raising awareness.

For more information, please visit www.myeloma.org.uk or email kate.morgan@myeloma.org.uk

How can we ensure that stakeholders are looking ahead to consider the market access challenges of the future?