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Leela Barham is a freelance health economist and policy expert. She has published in peer-reviewed journals and presented at national and international conferences. She has provided advice to the Department of Health and Social Care on policy on pricing of branded medicines to inform the negotiation of a successor to the UK’s Pharmaceutical Price Regulation Scheme (PPRS), the Voluntary Scheme for Branded Medicines Pricing and Access (VPAS), as well as worked with patient groups, the NHS, pharmaceutical companies and many others internationally on the economics of healthcare and pharmaceuticals. Contact Leela on email@example.com
The Accelerated Access Review, set up by UK Life Sciences Minister George Freeman in November 2014, aims to speed up access to innovation in the NHS. The review includes all kinds of innovation, from drugs, devices, diagnostics and even apps.
The Review has been building momentum, releasing the barriers to uptake of innovation in the NHS earlier in October 2015. This has now been followed by an interim report. This sets out five propositions that could help make adoption of innovation easier in the NHS. They are:
The interim report makes it clear that it is deliberately high level. The propositions need testing and ideas worked up. There are few concrete ideas being tabled – at the moment. One of these is a new ‘Innovation Partnership’ at the national level which links a network of Innovation Exchanges, facilitated by existing Academic Health Science Networks (AHSNs). The AHSNs were set up last time the NHS look at the issue of innovation, with the aim of connecting all relevant parties, including industry, across local patches in England.
Members of the new partnership proposed by the AAR, including the regulator the MHRA, the health technology assessment agency NICE, and NHS England as the payer and NHS Improvement, a merger of two previous agencies concerned with regulating the NHS, will all need to sign a concordat.
Other ideas stay at the concept level, so the details aren’t there to be able to judge what it really means for industry. Managed access and evaluation through commissioning would fit into this category, as well as an ‘evolved’ NICE process.
Significant efforts to engage
The interim report is short at just 23 pages; no mean feat when it is informed by what must amount to hundreds of pages of notes, comments, submissions and discussion. The AAR team has held 130 meetings, meeting 600 people, received 392 comments on their website, 54 submissions and ran a survey with responses from 97 people/organizations.
The result of all this engagement has been summarized in an independent report which includes ideas that stakeholders have come up with. Some of this needs to be read with a pinch of salt as they includes things that already happen as a matter of course; including a lay representative on NICE appraisal committees as an example (although perhaps making them more effective would be worthwhile).
Ongoing engagement on different price and reimbursement schemes
Despite all the engagement undertaken so far, the AAR plans more. This includes running a survey on the attractiveness of different models of pricing and reimbursement. The survey builds on work from Strategy& at PWC which looks at international approaches to pricing and reimbursement. Their work suggests that Price Volume Agreements, tendering and negotiation at scale, dose capping, conditional reimbursement and outcomes based payments are all ‘highly’ feasible in the UK.
Developing recommendations with input from all
The results of this survey will go into the existing mix of thinking that has been structured around four workstreams, each led by different organisations:
All of these are ‘underpinned’ by a patient and user engagement workstream, led by Hilary Newiss, National Voices.
All this work will also then go into the mix with discussion with the External Advisory Group, led by Prof Sir John Bell, a steering group chaired by the Department of Health (DH) which includes NHS England, NICE and the MHRA, the review team itself which includes staff from the Office of Life Sciences, and the DH and secondees from stakeholder organisations. Oh, and wider stakeholders (although just who has been left off the list?!). No-one will be able to veto recommendations that will be ultimately signed off by Sir Hugh Taylor, as the review’s lead.
A need to learn from previous efforts
Although the AAR has heavily engaged, the review makes no mention of the significant time and effort that has gone before it on the tricky issue of innovation. There’s no mention of Innovation, Health and Wealth for example. This 2011 report was all about innovation too; citing barriers and making a number of recommendations. It’s no surprise, but is a little disappointing, that there are strong echoes across the two pieces of work four years on. Some issues, like decommissioning (i.e. not spending money on things that turn out to be not as good as thought or should no longer be needed) was even noted as far back as Sir Ian Kennedy’s review of innovation back in 2009.
IHW was the work that introduced AHSNs. But it also did a lot more, including a NICE implementation collaborative (NIC), supported by a concordat. An IHW one year on report did come out, a refresh was thought to be coming out sometime in 2013 or 2014, and there’s a Department of Health funded evaluation on IHW although no report yet.
Things have moved on, not least the Health and Social Care Act which changed the NHS landscape from April 2013, so it’s right that innovation is looked at afresh, but at the same time, let’s not forget what previous efforts have taught us. Taking stock of what worked and what didn’t with IHW must surely feature heavily in the next round of work of the AAR, if it’s to give innovation the push that is needed. A difficult lesson is just how long something that sounds easy, like agreeing a concordat, can take. The NIC concordat was only signed in 2013, implying a long lead time when IHW was published in 2011. This time, can we afford to take so long?
Leela Barham is an independent health economist and policy expert. You can access her website here and contact her at firstname.lastname@example.org