E-drug: NICE & its implications (cont'd)
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Dear E-druggers,
Recent correspondence on this group has been fascinating - long may
it last! This is a longish message.
I would like to add to Joel's comments about co-payments, but more
particularly to give some background on NICE. This new body in the
UK is set to provide guidance on the introduction and management of
drugs (and devices, and surgical procedures) in the UK. The way in
which it will identify, select and appraise interventions is currently the
subject of a public consultation (more info from the Dept of Health.
The paper is titled Faster Access to Modern Treatments or something
like that!).
Industry is worried that this may be a de-facto 'fourth hurdle'
following on from licensing requirements. Roy Lilley's comments echo
the Association of British Pharmaceutical Industry's (ABPI) view that
NICE could be a 'bottle-neck'. Whether true or not, industry is trying
to manipulate the agenda, or so it seems to me. It is not the first time
that Lilley (a charismatic, though controversial, ex-health service
manager) has advocated an industry line.
There is another reason in the UK that 'loss-leaders' may be
important. Historically, hospital prescribing budgets in the UK have
been fixed, while primary care prescribing has not, though incentive
schemes and fundholding has attempted some form of controls
recently. 'Cost-shunting' onto primary care has been another tactic to
get brand loyalty for products in primary care. ie consultants initiate
on high cost, sometimes specialist, drugs and then GPs are left with
prescribing expensive products (NB I believe that about 80% of UK
prescribing costs are in primary care).
This is set to change - Primary Care Groups (PCGs) are being formed
(groups of practices covering approx 50,000 - 150, 000 population)
will have unified budgets (ie covering drugs and other community and
commissioning budgets). One of the debates is how GPs will ration
treatments and whether budgets will be 'vired' between interventions
- perhaps with drugs being seen as more 'cost-effective' than other
forms of interventions. Drug companies will be lobbying GPs even
harder I expect, as GPs get more control of planning for prescribing
decisions.
The issue of co-payments is interesting too. With the advent of
lifestyle drugs, many commentators in the UK are beginning to talk
about ways to ration treatments and there may be increased talk of
co-payments in the future. My thinking on this is that it is inevitable.
The principle of universality of care in the UK is untenable and
something has to give. We can moan about the way in which industry
has driven - is driving - the agenda - and we can argue that better
controls on industry would help (they would!) but this still does not
solve the problem in the UK. There needs to be some form of explicit,
systematic and democratic form of rationing. And, co-payments may
have to be part of the answer.
It is fascinating that this issue cuts across developed and 'developing'
countries. Am I right in thinking that 'revolving' funds are some sort of
sophisticated co-payment system or am I being stupid (the latter
would not surprise me!). Perhaps, once again, the UK can learn from
community-oriented solutions in so-called less developed countries!
With best wishes,
David Gilbert
Office for Public Management
252b Gray's Inn Road
London W1X 8JT
e-mail: scre@opm.co.uk
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