SEPTEMBER 2022
Guest editor: Graham Cookson | OHE Chief Executive
ABCD and E – An Alphabet of Priorities for the new Health Secretary
On Wednesday, Thérèse Coffey was appointed as Secretary of State for Health and Social Care following a cabinet reshuffle by the new UK Prime Minister, Liz Truss. Coffey - the third Health Secretary in three months – faces a myriad of problems including a workforce crisis with more than 130,000 vacancies, a real terms funding cut (of £9.4bn according to NHS Confederation), an over-run Accident & Emergency
system (30,000 people waited more than 12 hours to be admitted to hospital this July), an ever-growing waiting list (currently 6.7 m people) waiting for elective care, not to mention the “ticking time-bomb” that is social care. These challenges are set against a winter of discontent around the corner with seasonal flu, further waves of COVID-19, a cost-of-living crisis, and the real possibility of industrial action by NHS staff.
There is no doubt that this is a difficult Brief. However, there may be support from the top. The NHS was one of the three priorities that the new Prime Minister laid out in her maiden speech to the country. As a close ally of the PM and with her dual role as Deputy PM, all eyes will be on Dr Coffey to see if she can deliver.
Following her appointment, the new Secretary of State quickly listed her own priorities as ABCD – ambulances, backlog, care, doctors, and dentists. Within minutes, other stakeholders were lining up to make their claim for prioritisation and additional budget. The RCGP has stated that General Practice must be her “top priority” and that general practice “[…] is a service in crisis and in desperate need of support. GPs and our teams on the frontline are understaffed and under-supported and don’t have the time required to deliver the care our patients need […]”. Meanwhile, NHS Confederation – which represents the whole healthcare system – called for “investment in capital, in its workforce, and in our broken social care system.” The RCN was aggrieved that nurses, which comprise 30% of the NHS workforce, were absent from Coffey’s priorities, and called for higher pay for nurses.
I don’t disagree with the new Secretary of State’s priorities. Nor do I disagree with those added by other stakeholders. However, they all require an increase in funding, which cannot realistically be achieved by a reallocation of existing health and social care budgets. Yet, the new Prime Minister has stated clearly that she will pursue tax cuts, and there are rumours that the National Insurance rise will also be reversed. Whether more funding will be forthcoming and how this will be financed is a dilemma that will exercise Coffey’s Department as well as HM Treasury.
My suggestion, therefore, is to add to Coffey’s priorities an additional focus area that would help support all the other challenges. I would make it ABCD, E – for Efficiency. Making the health system more efficient – generating more output for a given level of inputs – would free up resources even within existing budgets to allocate to tackling other challenges. Even if funding is increased, it’s in everybody’s best interest to ensure that this is used in the most efficient manner possible.
OHE has produced research and insight on efficiency since we were founded 60 years ago. Some recent research provided case studies where health systems could tackle the 20% of expenditure that is estimated to be wasted every year. We also have a large, on-going project, funded by the Health Foundation, investigating labour productivity in primary care. Improving efficiency is no panacea, no silver bullet – but however much funding is available and wherever this is focused maximising efficiency will ensure that we deliver the most health care for patients, and in simple terms will stretch limited budgets to achieve the best possible outcomes.
MY TOP READ OF THE MONTH
“Broader and more equitable access to COVID-19 vaccines would not only reduce the health burden in lower-income countries, but simultaneously provide global macroeconomic benefits that far outweigh their cost.”
OHE colleagues, in a study funded by AstraZeneca, has produced a macro-level estimate of the global COVID-19 pandemic alongside an estimate of the value of access to COVID-19 vaccines. This well-evidenced and novel piece of research provides valuable insights as health systems wrestle with the aftermath of COVID-19 whilst planning for any future outbreaks. In 2021, 1.4 million direct deaths, 4.3 million excess (direct and indirect)
deaths and 6.0 million hospitalisations have been averted and hospital resources worth USD59 billion have been saved by COVID-19 vaccinations. However, whilst vaccines have been developed and deployed at an unprecedented speed, saving millions of lives and billions of dollars, the cost to high-income countries when not all countries are vaccinated far outweighs the cost of manufacturing and distributing vaccines globally. The authors find that advanced economies are conservatively expected to make a 28-fold return on investment in providing vaccine access to less advanced economies.
NEW OHE LITERATURE
Novel health technologies are routinely both cost-increasing and health-improving. Researchers and policy makers have used cost-effectiveness thresholds (CETs) to determine whether a technology’s health benefits are worth the additional cost. The use of CETs in health policy varies across countries and healthcare systems.
Recently, research on CETs has moved toward the development of new theoretical frameworks, based on supply and demand models for healthcare technologies. In the context of these models, numerous factors may influence the supply and demand of health technologies, such as the distribution of bargaining power, as well as the nature and dynamics of research and development costs.
In this article, we consider these policy-focused research developments and review relevant literature to explore what factors might be used to determine CETs in the future.
Novel oncology treatment strategies increasingly use medicines with distinct but complementary mechanisms of action in combination or in close sequence. Payers, when confronted with higher total cost of providing combination regimens involving multiple therapies, and usually longer treatment durations, are reluctant to reimburse them.
Nevertheless, depending on how value is attributed to the add-on versus the backbone, a clinically effective medicine used as part of a regimen that increases treatment duration might be found “not cost-effective at zero price”. This phenomenon, signalling a policy problem not a pricing issue, first needs to be better understood before a generalizable and transparent solution can be orchestrated.
This article sets out when this policy challenge arises and describes general principles that any proposed solution to the value attribution problem must satisfy.
Gene therapies represent a new era of medicine, offering the potential for truly transformational health gains, and further benefits for society and health systems. Given the potential long-term nature of the health gains associated with gene therapies, there is often substantial uncertainty in outcomes which complicates the use of conventional Health Technology Assessment (HTA) approaches.
Many of the challenges associated with the evaluation of gene therapies are not unique to these technologies, but it is well recognised that they face a high burden of these challenges. Therefore, to unlock the potentially transformational promise of gene therapy for patients and society, overcoming these barriers should be considered a priority. The recommendations provided in this report demonstrate the practical HTA tools available to work toward this goal.
NEWS HIGHLIGHTS
Algorithms are currently used to assist in a wide array of health care decisions. Despite the general utility of these health care algorithms, there is growing recognition that they may lead to unintended racially discriminatory practices, raising concerns about the potential for algorithmic bias.
When race and ethnicity are observed, many methodological approaches can be used to enforce equitable algorithmic performance. When race and ethnicity information is unavailable, which is often the case, imputing them can expand opportunities to not only identify and assess algorithmic bias but also combat it in both clinical and nonclinical settings.
In this new commentary piece, the authors describe two applications in which imputation of race and ethnicity can help mitigate potential algorithmic biases: equitable disease screening algorithms using machine learning and equitable pay-for-performance incentives.
An investigation by the BMJ has found that hospitals in England are facing a £2 million per month extra spend due to the on-going fuel price surge. The investigation showed that a number of trusts in England are worried they will have to make stark choices on staffing levels, waiting times and care provided in order to continue operating with energy costs predicted to be up to three times higher than a year ago.
Just one example is that of Great Ormond Street Hospital for Children NHS Foundation Trust in London, who are anticipating a “combined gas and electricity bill of around £650,000 a month in January and February 2023 – an increase from around £350,000 in the same months this year”.
NHS England has set aside £1.5 billion from its existing budget to cover the £485 million energy increase plus various other inflationary pressures on the NHS, however, energy prices have continued to rise and will have almost tripled for domestic consumers in the year to October 2022, almost doubling since April alone, and are predicted to rise again by 50% next year.
According to the Department of Health and Human Services, the U.S. government expects its supply of COVID-19 vaccines and antiviral treatments to run out over the next year and is preparing for them to be sold via the commercial market.
The lack of additional Congressional funding means supplies will run out earlier than expected, Assistant Secretary for Preparedness and Response Dawn O'Connell said. "We have always intended to transition this work to the commercial market and have been planning for that transition for some time now," she said. "Unfortunately, the timeline to make the transition has accelerated over the past six months without additional funds from Congress to support this work," she said.
The administration has procured enough of Pfizer's (PFE.N) antiviral treatment Paxlovid to supply the pills until mid-2023, O'Connell said, but other therapeutics made by Merck & Co (MRK.N) and AstraZeneca (AZN.L) are likely to be sold on the commercial market sooner.
UPCOMING EVENTS
HTA of Gene Therapies: Are Our Methods Fit for Purpose?
14 September | Virtual
Gene therapies have the potential to provide transformational health gains for patients and further benefits for health systems and society. However, there are number of challenges that can result in the potential benefits being overlooked and undervalued during HTA. In this webinar, webinar, commissioned and funded by Pfizer, experts will explore the challenges of HTA of gene therapies and recommend solutions to facilitate access, with a focus on the UK and the Netherlands.
Register your free ticket today.
Job Code: PP-UNP-GBR-1875
Date of Preparation: Sept 2022
How to fix the broken antibiotics market? Learnings from pilot
29 September | Virtual
Antibiotics are the foundation of medicine, but resistance and few new antibiotics pose a significant threat to society. In our upcoming webinar, Nick Crabb (NICE), David Glover (NHS England) and Jason Gordon (HEOR Consulting) to discuss why the market for antibiotics is broken and how we can fix it. Focussing on the learnings from the recent NICE-NHS England Antimicrobial Resistance Pilot they will debate the way forward - for the UK and beyond.
6 October | Hybrid
This year, for the first time, the OHE Annual Lecture is hybrid. You now have the opportunity to join us in London at the Royal College of Physicians or virtually from anywhere in the world on the evening of Thursday 6 October for our 2022 lecture 'Universal Health Coverage: more than just old wine in a new bottle?' presented by Eddy van Doorslaer.
Register your free ticket today.
