This guest post was written by David Watt, Managing Director of Autonomed.
Any new concept (drug/treatment/device) approved for prescription issue satisfied multiple, formal challenges in order to get there. Having gained approval however, it faces substantially greater obstacles from within NHS in the “roll-out” phase.
This example is based on an actual case of particular relevance to the prevention of diabetic foot ulcers.
- Current NHS cost for treatment of diabetic foot ulcers is £1billion p.a..
- 300 ulcers are diagnosed daily and every ulcer costs an average of £5,200 to treat.
- 50% of those diagnosed will not survive 5 years
- 80% of amputations are preceded by a foot ulcer.
Consequently a £17.45 orthotic called Liqua Care, clinically proven by the NHS to reduce the number of foot ulcers, available on NHS prescription, is a clear and quick win with major long term benefits and would logically be unilaterally adopted.
To implement efficiently, the three requirements are:
- Precedent: it must be listed on the UK Drug Tariff (the directory of all products able to be prescribed)
- those able to prescribe (eg GPs) need to know it exists and know the benefits of prescribing it
- those wishing to prescribe it need to be allowed to prescribe it
- Precedent (hence innovation) does not fit comfortably with procedure. As apparently the first application for a preventative device, exchanges were significantly protracted requiring submission of much more material than would otherwise be the case.
Having finally achieved formal NHS Prescription Services acceptance, broken links within the NHS then become apparent.
- A product formally proven (by the NHS) to reduce the number of ulcers, hence amputations, save lives, reduce a £1billion spend, able to be issued with insignificant financial exposure is now available on prescription but no internal vehicle exists to actively inform the clinicians. There is no “News at 10” within the NHS. Consequently a great deal of innovation is being missed.
- Pressure on CCGs to manage with budgetary constraints has severely damaged the “spend to save” concept.
- CCG local “formularies”, listing what subset from the Drug Tariff is allowed to be prescribed appear in many instances to be out of date and lacking in ownership. A clinician may wish to prescribe something that is fully NHS approved, but if it is not featured in the local CCG formulary, in effect it does not exist.
Subsequent obstacle is selective interpretation of output from NICE/SIGN – bodies whose purpose includes issuing guidelines which in reality can be used as a means of avoiding change.
- Generalisations in NICE guidelines can be used/misused as a means of maintaining the status quo, impeding change. NICE guidelines should be observed but because, by definition, they are likely to be out of date before they are even issued, they should not be considered definitive. Because NICE will not have addressed the minutiae of options available should not prevent their adoption.
The due diligence, challenges and assessments undertaken by NHS Prescription Services should not be regarded as some preliminary to a repetitive scenario with another NHS/DoH body. The processes are concise, in-depth, challenging and rigorous. Anything that passes muster with Prescription Services is fit for purpose.
Justification exists for an NHS “bridge” that sits between Prescription Services and the “coal face” at the CCGs to diffuse information concerning new technology on the Drug Tariff.
The components already exist – they need only be connected in a joined-up fashion. The information could be summarised to include patient indications, product efficacy and health economics. As the source is the NHS itself, it is instantly credible.
Failure to do so – the scenario at the moment – is untenable. New advances have been introduced that are able to provide enormous savings in terms of NHS expenditure, patient quality of life and patient’s lives but are thwarted due to inefficient, ill defined systems that are being used for the wrong purposes.
Millions are spent on foot assessments but unlike screening for (say) cancers, little, if any action is being taken when a patient is demonstrably at risk, instead awaiting the inevitable. The big picture is simply being overlooked.
The tools exist, they are proven, they are cost effective. There is absolutely no excuse not to break the status quo. All parties, be they political or otherwise are in agreement that the current situation needs to change – this only requires using the resources that are already in place.
This is just one example – there will be more, continuing every time an innovative solution is forwarded.
Effective process change and communication within the NHS to free up these logjams is long overdue.
The views and opinions expressed herein are those of the author and do not necessarily reflect the views of the APPG.