Is pharma missing key opportunities in private healthcare?

“No decision about me, without me!”

Unless you’ve been living on Mars in recent years, you’ll be well aware that the NHS mantra is supposed to demonstrate its commitment to giving patients much more say over their care and treatment. Of course, this doesn’t only apply to involvement in decision-making about medications, interventions and procedures, but also to the choice of provider who delivers the care and the setting in which it is delivered. 

As the emphasis on patient choice grows, there is increased recognition that at different stages in their overall care, patients are entitled to choose freely between NHS and private treatment; whether provided as a private service by an NHS body or by the independent sector.

 As a result, we are now seeing an increased demand to mix elements of privately and publicly-funded care for a single course of treatment.  It seems that patients are selecting private provision in specific circumstances; because they believe the NHS does not or cannot provide a clinically indicated aspect of the treatment due to concerns about its relative cost-effectiveness.

Alongside this growing trend in mixing private and publicly-funded care, there has also been double-digit growth in the self-pay element of the private healthcare market. Patients are increasingly choosing to self-fund their treatment and pay out of their own pocket. This trend is set to continue. For example, according to “The Private Healthcare UK Self-Pay Market Study 2015” from Intuition Communication, publishers of Private Healthcare UK, the London self-pay market is estimated to be growing at 20% annually.

Growth in self-pay treatment has been seen especially in cardiology, interventional radiology, dermatology and gastroenterology and there has also been a marked rise in the number of oncology patients.

The rising cost of private medical insurance premiums is one of the reasons behind the growth in self-pay (and as a result, there has been some decline in patient numbers in another part of the private healthcare sector); however, there are also many other factors behind the growth. Consequently, the private healthcare market is growing exponentially with annual growth of 5% forecast between now and 2016 – and strong growth in the sector is also promised for years to come.

One of the primary reasons for the greater interest in self-paying, via the private route, is the perception that private patients have less restricted treatment options in comparison to the NHS. The belief being that they can access treatments that are either no longer available on the NHS or treatments which have failed to secure NHS funding due to NICE restrictions. Indeed, many private providers openly promote the availability of the latest advances in medical technology that are not available through the NHS.   

Another perceived key benefit is that consultations usually take place more quickly privately compared to long NHS waiting lists. 

In short, some people are increasingly taking healthcare into their own hands because cuts mean they don’t qualify for treatment and others would rather pay than wait.  

Therapy areas not traditionally associated with “going private”

It is also interesting that in recent years many private medical insurers have extended their scope. Many now cover a vast range of conditions (albeit under certain circumstances) including ones that wouldn’t traditionally be associated with private medical insurance e.g. diabetes, respiratory conditions and multiple sclerosis.

Plus in recent years many private insurers have started to embrace oncology. Certain Bupa membership policies for example provide access to proven eligible cancer drugs and treatments and new drugs (following specialist recommendation) – as long as it has been licensed by the European Medicines Agency for the condition and is included on their list of advanced therapies and specialist drugs. Exceptions are made in some circumstances when a treatment is part of a clinical trial, following review and approval by Bupa.

With a number of drugs being delisted from the Cancer Drugs Fund in March 2015 and difficulties obtaining access to cancer treatments following stringent NICE approval,  there is a widespread and growing perception that only private healthcare offers patients a way through to access treatments that are not readily available via the NHS.

Pharma therefore needs to be investigating the following…

For many in pharma, the private market is often an afterthought. But with trends like these, perhaps the time is right to truly get to grips with this market opportunity?

After all, this sector could be fertile ground for usage of your product pre-NICE, not to mention those who have experienced the rigours of NICE negative rulings and now need to explore other avenues such as the private sector to secure access for your product.

Whatever the scenario, Adelphi’s experience indicates that the private market is a very different “kettle of fish” from the public sector. For those marketeers who want to ensure real success in private healthcare, we suggest you need to start by conducting comprehensive market research which will deliver an in-depth understanding of how the market operates.

There are numerous considerations which make it a very different world from the NHS. Below is just a taster of the sorts of topics which typically need to be explored….. 

• Who is the self-pay patient? What do they actually look like?
• What is the decision-making process for the use of new medicines in private healthcare?
• Is there a formulary or not?  If so, at what level?
• What degree of clinical autonomy do HCPs have compared to the NHS?
• How easy is it to access physicians who work in the private setting?
• How likely are physicians to use a new product in the private sector?
• What is the relationship between the private provider and the private insurer?
• How does this relationship impact on medicines usage/authorisation for usage?
• Do private insurers actually input into medical decisions?
• What is the role of the pharmacist?   
• How interventional is the pharmacist in prescribing decisions for private patients?
• Are private healthcare insurers and providers willing to interact/negotiate with pharma?

This article was written by Adelphi’s NHS Leads Judy Norcross, Research Director and Claire Nelson, Associate Director.

For more information on NHS and Market Access Research contact aruk@adelphigroup.com

Is pharmacy’s ‘time’ finally here?

For almost thirty years, multiple studies have suggested that community pharmacies should perform a broader role. Screeds have been written about the need for pharmacies to move away from relying on their traditional role as dispensers and to be more involved in patient care. But despite the aspirations of many, it is a fact that progress has been slow and challenges myriad. 

However, in today’s NHS with its unprecedented budgetary pressures and countless frenetic searches for ways to do more for less, could it mean that pharmacy’s ‘time’ is finally here?  Has the moment finally arrived when the pace of change will gather momentum?  Especially as it now coincides with a time when the traditional model of dispensing is threatened by the advent of new technology.

Adelphi thinks it definitely looks that way…

Pharmacy Development – in the Spotlight since Late 2013 - with NHS England Supporting Change

In November 2013, the issue came under the spotlight again when the Royal Pharmaceutical Society (RPS) published ‘Now or Never: Shaping Pharmacy for the Future’. Based upon the Society’s Future Models of Care Commission, the report was intended to provide a coherent narrative for pharmacy reform. It reported that many pharmacies were keen to develop innovative ways of delivering patient care, particularly under the banner of medicines optimisation. It also reported at least 100 examples where this had already started to happen.

NHS England supports this move and has published many documents outlining how community pharmacy can play a greater role. For example, in November 2013, it produced its vision for the future of urgent emergency services in England. The report highlighted that 20% of GP consultations related to minor ailments and suggested that these could be largely dealt with by self-care supported by community pharmacy.

The NHS Five Year Forward View also described the need to make far greater use of pharmacies not only with minor ailments but also in illness prevention and support for healthy living, in medication reviews in care homes and as part of more integrated local care models.

What sorts of additional services do some Community Pharmacies currently provide?

It is a fact that every year in England, 438 million visits are made to community pharmacy for health-related reasons¹. Around £300 million per year of medicines are wasted in primary care and between 30% and 50% of prescribed medicines are not taken as recommended¹.

There is therefore little doubt that community pharmacy is ideally placed to support the objectives of medicines optimisation. 

For example, advanced services can be provided by pharmacies upon accreditation such as Medicine Use Reviews (MURs), Appliance Use Reviews (AURs) and the New Medicine Service (NMS) – to support patients with long-term conditions who have been prescribed new medicines, and the provision of stoma and medical equipment.

MURs are consultations between the pharmacist and the patient about how they use their medicines and to find out more about the patient.  This service is supplementary to more in-depth clinical reviews conducted by GPs. There has been a steady increase in the number of pharmacies offering this service to patients.  

Most pharmacies also provide New Medicine Service (NMS) for patients that have received their first prescription for a medicine to treat the following conditions:

·                     Asthma

·                     Lung conditions (e.g. bronchitis and emphysema)

·                     Type 2 diabetes

·                     High blood pressure

·                     Blood clotting disorders

Summary of Advanced Services provided 2013-14²

These are just a few examples. There are also a range of enhanced services which might be commissioned from pharmacies by NHS England or Public Health at a local level e.g. stop smoking services, alcohol advice, sexual health checks, NHS health checks etc, etc.

Additional Models of Care

In addition, based on our extensive experience of researching this customer group, we know that many pharmacies have also extended the scope and reach of their pharmaceutical care services in a whole host of other ways in order to provide an array of patient-orientated services and care.  

Therefore, in reality, all sorts of service developments have been put in place to help CCGs to address some of the key issues facing the NHS e.g. access to out-of-hours diagnosis, care of the elderly and vulnerable people, helping people to get and stay out of hospital etc, etc. These are sometimes ‘one-off’ developments and sometimes developments which extend across a chain of regional or national pharmacies.

Overview of Models of Care 

What opportunities are there for pharma to engage with community pharmacy?

So what does all this mean for pharma? In those situations where community pharmacies have taken on a broader role as caregivers, what might pharma do to support the services that they offer?     

Is there an opportunity for pharma companies to support those that are providing models of care which impact the delivery of service or medicines in a therapy area of relevance to their portfolios?  If so, what would the support need to look like and what kinds of help would these customers most value and why?

It is fundamental to start by asking if the brand team truly understands the needs and motivations of this customer group – customers who according to the RPS have long been marginalised by colleagues in the NHS.

Adelphi suggests that developing an in-depth understanding will be critical in order to inform the development of a strategy.  This is a complex customer group.  In our experience, it is usually necessary to thoroughly explore different pharmacy/pharmacist customer segments and also ‘dig deep’ to uncover the realities. Not all pharmacies think or act the same, nor is the reality of this world necessarily what is published in the press.  Much of it is ‘closed’ because it is competitively sensitive and therefore has to be uncovered by tact, diplomacy and establishing a good rapport with respondents.  

Any primary research also needs to think carefully about which respondent types are likely to be able to provide an informed perspective of ‘the truth’.

In summary, the companies that ‘dig deep’ to truly get a handle on needs, motivations and realities before devising a pharmacy strategy will be the ones that stand the greatest chance of success.

1.  Medicines Optimisation: Helping patients to make the most of medicines. Good practice guidance for healthcare professionals in England (May 2013)

2.  General Pharmaceutical Services, England 2004-05 to 2013-14 (Nov 2014) Health & Social Care Information Centre (National Statistics)

How are payers reacting to the CDF’s decision to cut 16 drugs?

Recent changes to the Cancer Drugs Fund (CDF) have been somewhat controversial. We have seen the budget increase from £200 million in 2013/14 to £280 million in 2014/15 and an estimated £340 million from April 2015, but 16 drugs (covering 25 indications) out of 84 drugs will be cut.

Peter Clark, chair of the CDF maintained that they “have been through a robust, evidence-based process to ensure the drugs available offer the best clinical benefit, getting the most for patients from every pound”. But some pharma companies and the ABPI’s, chief executive, Stephen Whitehead described the process that led to the decision as flawed.

Stephen Whitehead described the CDF as a “sticking plaster”. He believes “the solution to this issue remains the urgent reform of NICE which will ensure that the right patients get the right medicines at the right time whatever their condition.” Eric Low, chief executive of Myeloma UK labelled the CDF as a “quick-fix measure” that is not an “effective long-term solution to securing cancer patients access to medicines”.

But what do the ‘people on the ground’ think?

We used Adelphi’s comprehensive multi–relational database of key NHS contacts to find out payer’s views on this controversial topic. Here are some of the things they said:

Generally it seems that many payers think that the NHS faces huge challenges. Whilst payers are very sympathetic towards individual patients, the general consensus is that it was a tough decision that had to be made to optimise the use of finite resources.

As the general election approaches it will be interesting to see the extent to which politicians heed NHS stakeholders’ pleas for a more wholesale restructure of the NHS funding process.

What are the implications of the silo fund on market access?

It was very interesting to see last week that NHS England enacted an £18.7 million funding stream to expedite market access for a single medicine – Gilead’s new Hep C drug Sovaldi (sofosbuvir) in combination with the antiviral ledipasvir. The silo fund was originally approved in April and is now ‘open for business’. The recommendation of the body’s Clinical Priorities Advisory Group (CPAG) means that whilst the drug goes through the NICE process, Sovaldi will be funded for those hep C patients at significant risk of mortality – or who require liver transplantation.’

Consequently many patients with acute liver failure or awaiting transplants can gain early access to Sovaldi whereas previously they would have had to have waited for NICE approval. This is the second time the NHS has intervened to fund a particular disease – following the Cancer Drugs Fund (CDF) but it’s the first time a single drug has been given its own unique cash stream.

Ben Adams has written an excellent article covering this that’s worth a read in the PharmaFocus Market Access supplement

In parallel to this, last week Sir Andrew Dillon, Chief Executive of NICE, is reported in PharmaTimes to have said ‘NICE vs. CDF makes no sense’. He told the Health select Committee that there was a misalignment in the approach NICE takes regarding willingness to pay vs. the CDF. An example of this is Roche’s Kadcyla (trastuzumab emtansine). NICE rejected the drug to treat women with aggressive breast cancer last month based on an assessment of QALY – but the drug can be accessed through the CDF.

We've been mulling over some questions in the office this week about this...

How will NICE, the CDF and Silo funds work together in the future? Which other new, exciting drugs outside of oncology might go down the route of these new silo funds? And what will this mean for NICE – how will the NHS ratify their decisions between the different channels?

This could be a new opportunity for patients to gain access to life-changing medicines that previously may not have been available to them, but there’s also the potential for it to become a whole new political hot potato!