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NEWS: Susan Mayor NHS pays £500m too much for prescription drugs BMJ 2007; 334: 383 [Full text]

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Hardly a new finding

Andrew P Moltu, Susan Major   (24 February 2007)

Rather old news really

John D K Pope   (28 February 2007)

Fair prices for new drugs and insulin discontinuations

Alan Meakin, Peter D Burrill   (20 April 2007)

Hardly a new finding 24 February 2007
Andrew P Moltu, GP Limes Medical Centre, Narborough, Leicestershire LE19 2DU, Susan Major Send response to journal: Re: Hardly a new finding	The NHS has spent vastly more than it needed too for years! Almost a decade ago I remember seeing the pharmacy bill of a patient who had been prescribed a quinolone antibiotic in Spain. At that time the retail price he paid was less than the basic NHS price of the same drug! I remember thinking how on earth could the NHS, possibly the biggest purchaser of medicines in the world, have agreed a price that was more than free market retail price? The answer is weak politicians who fail to be firm with drug companies who threaten to pull out of the UK. How can the NHS save money - look beyond squeezing the staff costs and look at the rediculous amounts it overpays for buildings, equipment and supplies? This applies not just to the NHS but to the public sector as a whole. Suppliers, builders and the like know that they can charge almost what they like where the public sector is involved. Competing interests: None declared
Rather old news really 28 February 2007
John D K Pope, sessional GP Scotland-locum Send response to journal: Re: Rather old news really	This has been the status quo for years. I recall when Zovirax was first introduced, it was costly, albeit very effective. A friend happened to visit from USA- a rich banker- who had developed Herpes Zoster just prior to his trip. His physician in San Fransisco had prescribed Zovirax- and the cost was less than 2/3 of what it then cost in UK. He was continuing round the world, and later told me that he had ascertained that the drug cost only half the UK cost in Hong Kong. And that for a drug produced and tested in UK!! I certainly had something to say to our loval drug rep, next time he called for a coffee.... Competing interests: None declared
Fair prices for new drugs and insulin discontinuations 20 April 2007
Alan Meakin, Medical Director Derbyshire County PCT, Chesterfield, S41 7PF, Peter D Burrill Send response to journal: Re: Fair prices for new drugs and insulin discontinuations	The Office of Fair Trading (OFT) has recommended that the Pharmaceutical Price Regulation Scheme (PPRS) should be reformed, to deliver better value for money from NHS expenditure on drugs and to focus business investment on drugs that have the greatest benefit for patients (1). The strands of the PPRS are such that many of the outcomes run counter to the interests of the NHS. High prices at launch are essentially inevitable, drugs are developed (and rewarded) that do not necessarily offer clinical advantage, and the industry alone determines prices according to what they believe to be their product’s value (2). The price of a new drug does not relate at all to that of its immediate predecessor. The more severe the disease, the more expensive will be the drug created to treat it, even if it is of dubious or limited efficacy. The benefits to patients of the vast majority of new drugs may be marginally greater than those of the old ones, but their prices will be disproportionately greater (3). The OFT’s study identifies a number of drugs where prices are out of line with patient benefits. The study recommends that the current ‘profit -cap and price-cut’ scheme be replaced with a patient-focussed, value- based pricing scheme, in which the prices the NHS pays for medicines reflect the therapeutic benefits they bring to patients. This would enable the NHS to obtain greater value for money from its existing drug spend. It has been suggested that the price of any new drug should be capped so that the increase over the price of the previous treatment is proportional to the improvement in effectiveness (3). So if effectiveness is 10% better, then the price should be no more than 10-15% more than that of its conventional equivalent. In the case of breakthrough drugs with no therapeutic predecessors, price could be determined by regulatory bodies on the bases of the potential market and the expected benefit to the population and would not depend on the caprice of the manufacturer (3). That brings us to the subject of insulin discontinuations and the financial consequences. Health professionals received a letter from Novo Nordisk in July 2006 informing them that the majority of strengths of Mixtard Penfill and Velosulin vials would no longer be available after the end of this year. The letter states “current treatment trends supported by clinical evidence indicate that analogue insulin is now a preferred option”. Insulin analogue manufacturers are relentlessly promoting the use of insulin analogues and many clinicians are prescribing them as first -line treatments (4). Insulin analogues are more expensive than the standard insulins and robust evidence that they are a significant advance is lacking (5,6,7). For instance, the HTA report (6) concludes “there appears to be no improvement in long-term glycaemic control and therefore insulin glargine is unlikely to reduce the incidence of the long-term microvascular and cardiovascular complications of diabetes”. The DTB (7) concludes “we recognise that the analogues are being used increasingly as first-line therapy for patients with diabetes requiring insulin. However, in our view, this approach is not justified given what still needs to be established about the analogues’ long-term benefits and safety. Also, there is no convincing evidence to justify switching patients from existing conventional therapy to analogues if they have appropriate glycaemic control without troublesome hypoglycaemia”. Unfortunately, manufacturers discontinuing well established, safe and cost-effective insulins are forcing switching upon us. This will cause patients unnecessary inconvenience and possibly distress, will take up staff time, and create unnecessary cost pressures on already stretched drug budgets. Perhaps there is a solution linked to the OFT report. According to Bloomberg.com, Eli Lilly, Novo Nordisk and Sanofi Aventis are cutting insulin prices in Germany after the health ministry said new versions of the diabetes therapy aren’t worth their cost (8). So we ask the Department of Health to act. If you cannot stop drug companies discontinuing safe and cost-effective drugs, at least get them to reduce the price of the ones we will have to use instead. 1. Office of Fair Trading. The PPRS, an OFT market study. London, February 2007 2. Collier J. BMJ 2007; 334; 435-6 3. Sotelo J BMJ 2007; 334; 369 4. Gummerson I. Pharm J 2006; 277:169-72 5. Siebenhofer A et al. Cochrane 2006, Issue 2 6. Warren E et al. HTA 2004; 8(45): 1-72 7. Anon. DTB 2004; 10(42): 77-80 8. www.bloomberg.com/apps/news?pid=20601100&refer=germany&sid=avoesmntqlRY (accessed 22/03/07) Competing interests: None declared