ABPI Response to the Consultation on:
Securing Our Future Health: Taking a Long Term View - Interim Report
(Wanless Report)

1.         Overview  

1.1       ABPI welcomes the general tenor and conclusions of the Wanless report, and its contribution to expanding the debate over the quality, extent and funding of the NHS.  

1.2       We regret that the terms of reference restricted the scope of the enquiry to “a publicly funded service” since it is our belief that all options should be examined. To this end, we especially welcome the fact that it was necessary “to consider whether the method of funding the health service is itself a factor in determining the resources required.” (see para 2.16 of the Wanless report).

1.3       It may be assumed that in relation to other areas where we make no comment that ABPI is generally in agreement with the comments, analysis and conclusions. Our comments set out below are focussed on areas that are, in our opinion, of particular significance or where we disagree with the conclusions reached.  

1.4       Our comments below are cross-referred to relevant paragraphs of the Wanless report itself.  

2.         Detailed comments  

2.3              We endorse the contents of this paragraph and would highlight the role of medicines in extending life expectancy. We would also highlight the relative cheapness of modern medicines used in primary care as compared to treatment in the secondary or tertiary sectors. Patients in the UK are currently amongst the lowest users of medicines per capita and we believe that GDP could be further improved by the appropriate use of modern medicines  

2.16          We note the comments and believe that this further highlights the need to review not only the extent of resources available but also the alternative funding mechanisms which might be available (see 1.2 above). The UK spends less per head of population on health care than almost all other European nations which clearly exacerbates the situation.  

2.22          The report fails to acknowledge the link between public funding and excessive political interference with the management of the NHS, sometimes at a wholly inappropriate level of detail. It also fails to acknowledge the inflexibility of public funding when increases to improve service or finance technological advance are required. Tax changes, requiring political effort, are significantly less flexible and potentially take longer than consumer choice in a true market scenario.  

2.22

2.23     We fully endorse the concern expressed about limited scope for “expression of individual preference and choice” – which should apply to both patient demand for service and NHS supply of services to meet that demand.  

2.27          The pharmaceutical industry has extensive experience in the setting of and achieving measurable goals and objectives. We are strong believers in the maxim “you get what you measure”. This makes it critically important that any measures used to assess performance in the NHS be meaningful, and measure outputs rather than inputs. We acknowledge the difficulty in defining these, but believe that crude measures such as waiting lists result in misallocation of effort and funding away from real priorities which would be of greater benefit to the nation’s and individual health. We would be happy to supply examples if these are required.  

It is our belief that there should be stronger integration of performance assessment process and measures and clinical outcomes.  

2.29     We strongly welcome the recognition that “more healthcare resources and a larger share of publicly funded healthcare are associated with better health outcomes” and would also draw attention to the recent article in the BMJ (BMJ volume 324 – 19^th January 2002, page 135) which, as far as we are aware, for the first time shows real evidence that the NHS is not necessarily the most efficient way to deliver a health service.  

2.30          It takes a minimum of 8 years from the day a student starts medical training to the point when they can practice on their own as a GP or consultant. There can therefore be little impact on the doctor per head ratio this decade, unless people are brought in from abroad (and that has impact on the health systems in the “exporting” countries). This highlights the chronic need for long term and ongoing commitment to the training and development of all professional staff, and the need to make their terms and conditions of employment attractive to retain them.  

2.32          We fully understand the need for the assumption that the Government achieves its central economic objective of delivering economic stability and rising prosperity.  We feel however that it is appropriate to consider the implications should this not be achieved. In such circumstances, reliance on public funding of health care will inevitably reduce the resources available, and this again highlights the restricted scope of the enquiry and the restricted choice therefore available.  

2.33          The downside of the disease-by-disease approach is that it may not fully take into account diseases which currently only use very limited health service resources, but where technological advances may create substantial patient benefits. Examples of such diseases today would include Multiple Sclerosis and Alzheimer’s. Who can say what they might be in the future, but in a report such as this, looking to the future, this is a critical factor to be taken into account.  

2.37          We strongly support and agree with the expected changes identified for “tomorrow’s patient” – indeed the majority have arrived, to a varying extent, today.  

2.39

2.43          (Questions7.3, 8.1)  It is our belief – based on experience in pharmaceuticals – that there will be increasing litigation in the health care arena, and this needs to be taken into account in all aspects of planning. It needs to impact resource requirements, and should also be a major factor in reviewing and potentially changing the respective responsibilities of the patient and the health care system.  

2.48          The impact of demographics on the future demand for health care services is acknowledged. It is our belief that quality of life for individual patients should have greater prominence in decision making. We recognise that this raises significant moral and ethical issues and would welcome a wider debate on these matters since they have such a potentially large impact on the health service and resources required.  

2.51          In defining the needs of the elderly, the wider costs and implications to society must be fully taken into account. Loss of confidence arising from excessive media focus on crime – at a time when crime rates are falling – is one example. The difficulty of families supporting elderly and/or sick relatives at home because of the design of modern housing (eg the three bed semi) is another.  

2.55          (Question 9.5)  A substantial part of the cost of the health service arises from what might be defined as “self inflicted” problems:  

·              Smoking

·              Obesity

·              Lack of exercise

·              Alcohol related accidents

·              Recreational drugs  

We are not saying that all cases of issues arising from such causes are self-inflicted.  

We would welcome changes in the delivery and funding of the health service that acknowledges this and one way of achieving this could be through a greater emphasis on prevention and education.  It is our belief that there should also be an increase the level of individual responsibility for individual health. As suggested in the report, a substantial increase in the resources devoted to prevention would, we believe, make a significant contribution. At the same time, it is our belief that the frequent comments that are made (not in the Wanless report but in the wider debate) about patient rights should be accompanied by an equivalent emphasis on both patient and public responsibilities relating to health.  

2.58          We fully agree that technology is a crucial driver, not only of health spending but also health improvement. To this end we believe that it would be mutually advantageous to both government and the industries that supply and support the health service if there were to be closer dialogue and mutual understanding of developments so that funding can be in place when required rather than appearing to be always seeking to catch up. One possible vehicle for such a dialogue would be the Pharmaceutical Industry Competitiveness Task Force (PICTF).  

The contribution of technology to health improvement is itself driven by the medicines industry in the UK spending more than £8 million every day on Research and Development, with the total annual sum (£3,696 million in 2000) being greater than for any other European country. We invest more than 30% of our sales in R & D, and contribute more than 35% of all spending by industry in the UK on R & D.  

2.59     In the context of catching up, we would question whether history is an accurate guide for the future in terms of the increases in expenditure created by technology and suggest that the 2% assumption could well not be sufficient.  

2.61          We strongly support the assertion that the UK has been slow to adopt new technologies – there is substantial evidence of this in relation to medicines (which can be supplied if required). We also welcome the acknowledgement that positive evidence-based recommendations need to be resourced. We particularly welcome the implicit acknowledgement of the substantial contribution that medicines make to health care, and indeed the fact that medicines, whilst adding cost as technology advances, also save significant health service resources. This can be demonstrated if required.  

2.63          NSFs will only add to the resources required if those resources are made available to those actually charged with delivering that NSF. It should be noted that not all NSFs fall into areas currently identified as top priority by government (e.g. diabetes, renal, long term illness etc). It is certainly the case that if all NSFs are implemented in full across all relevant patents then expenditure will increase.  

The use of medicines to reduce the risk of disease will also increase expenditure in the short term whilst yielding longer term savings. Preventative medicine requires an initial up front investment.  

New treatments for some diseases (e.g. Alzheimers) will increase health expenditure. However, if a whole systems approach is taken then overall costs may in fact fall as the treatment impacts on other government and national budgets. Examples of such situations are available if required.  

2.64          The potential for new medicinal technologies to impact is probably 5 – 10 years away. When available, it is believed that they will enable a far more precise targeting of the effective and appropriate medicine to individual patents, and thus in this respect may help to reduce expenditure. However, it is also expected that technology will enable many diseases to be treated and/or cured that cannot be addressed by medicines today.  

A factor that also needs to be taken into account, and which may be available in a shorter timescale, is the improved ability to diagnose and identify illness and the appropriate treatment. Some of this will be achievable on a remote basis through the use of already existing communications technology.  

2.69

2.70          We strongly endorse the need for improved recruitment, retention and development of staff within the health service. The Pharmaceutical Industry is a prime example of an industry that not only invests in Research and Development, bricks and mortar and markets, but also extensively in its people. The results speak for themselves, and have been independently acknowledged by Pharmaceutical Industry Competitiveness Task Force (PICTF).  

But it is not only training and development. Public acknowledgement of the role, effort, and commitment etc of health service staff is vital to restore and develop self-esteem and pride. We believe that a sustained campaign to this effect is essential to securing ongoing public support and commitment to the health service.  

2.73     We fully support the concept of increasing self-care by patients. For this to be effective it requires good, reliable information, more than is currently available. We believe that this can only be achieved by a review of current practice and regulations. We also welcome and support the “Expert Patient” initiative of the Dept of Health, but believe that this will be difficult to implement without improved information.  

We believe that the electronic patient record will provide a basis for increased use of information technology, improving efficiency and also allowing quality to develop. Such a development will also increase the opportunities for co-operation with industry in the fields of research and development and measuring effectiveness. It should also permit a growth in self-care, which will hopefully encourage greater individual responsibility (see 2.55 above).  

We fully support the development and use of evidence based guidelines, and their implications across the health service. However, we feel that these should only be created from fresh where existing guidelines are not available or are not to the right standard. We are dismayed when resources are apparently wasted because, for some reason, existing guidelines such as those produced by SIGN are apparently ignored.  

It is important, whilst directing resources to treatments that are cost-effective, that other disease areas (including but not limited to so called orphan diseases) are not ignored. These people also need and should have access to care and attention.  

2.74

2.75.1    Variation should be encouraged in models of service delivery. The health service needs central core values and standards, but should encourage local diversity in delivery to secure and foster innovation and experimentation that, if successful, can then be promulgated and shared.