1.  INTRODUCTION

  1.1  Roche Products Ltd is a major producer of innovative medicines for a variety of medical conditions, including cancer, kidney disease, autoimmune disorders, osteoporosis, obesity and hepatitis C.

  1.2  Unfortunately health inequalities remain a significant challenge in many of the conditions in which we have an expertise. We collect a great deal of data and intelligence on different aspects of primary care services which we believe can contribute to more informed policies to tackle health inequalities and we therefore welcome the opportunity to submit evidence to this inquiry.

  1.3  Health inequalities can manifest themselves in a number of ways, including:

—  Variations in a person's likelihood of developing a medical condition

—  Variations in a person's health outcomes once they have developed a condition

—  Variations in a person's experience of health services

  1.4  These variations may depend on factors such as their geographical location, social class, ethnicity, age or gender. We would welcome recognition by the Committee of the different kinds of health inequality that exist and the different ways in which these can manifest themselves. Different interventions will be required to address these variations. Our response focuses on:

—  The extent to which the NHS can contribute to reducing health inequalities

—  The distribution and quality of GP services and their influence on health inequalities

—  The effectiveness of public health services at reducing inequalities

2.  THE EXTENT TO WHICH THE NHS CAN CONTRIBUTE TO REDUCING HEALTH INEQUALITIES

  2.1  A key challenge to our ability to effectively tackle health inequalities is collecting high quality evidence about the form which inequalities take and the interventions which are most effective in addressing them. In the field of cancer, evidence is continuing to develop about the nature of inequalities. For example, an analysis by the Men's Health Forum has shown that, for the ten commonest cancers which affect both men and women, age standardised mortality rates are in every case higher in men.[352] Yet the reasons for this remain poorly understood. We therefore welcome the Department of Health's commitment to establish a National Cancer Equality Initiative, bringing together key stakeholders from the professions, voluntary sector, academia and equality groups to develop research proposals on cancer inequalities, test interventions and advise on the development of wider policy. We would welcome a recommendation from the Committee that this initiative should be replicated for other conditions.

  2.2  The Inquiry's terms of reference rightly states that there are many wider social determinants of health inequalities which it will be difficult for health services alone to influence. Factors such as housing, income inequality and education play a particularly important role in determining variations in a person's likelihood of developing a medical condition. However, preventative health services for conditions such as obesity or smoking clearly have a vital role to play in tackling inequalities.

  2.3  Equally, the role of health services will be central to reducing unnecessary variations in a person's health outcomes once they have developed a condition and their overall experience of health services.

  2.4  For example, ensuring that every person has prompt access to clinically and cost effective treatments, irrespective of geographical location, age or ability to pay is a vital element of reducing variations in clinical outcome. Roche collects a great deal of data on access to medicines for conditions such as cancer. Unfortunately significant inequalities remain in access to these medicines, even when NICE guidance has been available for some time. We welcome the recognition by the Department of Health in the recent Cancer Reform Strategy that significant variations remain in access to NICE-approved cancer medicines and the commitment to continue to monitor and where necessary address these.[353]

Figure 17: Estimated cost per head of NICE-approved cancer drugs used in hospitals in
Jan-Jun 2005, by cancer network

  2.5  We have evidence that these variations also exist in other disease areas, including rheumatoid arthritis, osteoporosis and hepatitis C. Tackling such variations will be important in addressing inequalities in health outcome. We would welcome recognition by the Committee of the continuing issue of variations in access to treatment and the importance of addressing this as part of wider efforts to tackle health inequalities.

3.  THE DISTRIBUTION AND QUALITY OF GP SERVICES AND THEIR INFLUENCE ON HEALTH INEQUALITIES

  3.1  In recent months there has been a great deal of welcome scrutiny of the distribution and quality of GP services. We believe that it is important that access to wider primary care services is also considered as groups such as pharmacists and community nurses can play an important role in tackling health inequalities.

  3.2  In relation to GP services, "levers" such as the Quality and Outcomes Framework (QOF) and practice based commissioning (PBC) offer significant opportunities to incentivise further action to address health inequalities.

Quality and Outcomes Framework

  3.3  The QOF is the annual reward and incentive scheme which operates as part of the General Medical Services contract. Introduced in April 2004, it contains a series of performance-based indicators for practice organisation and management and a range of evidence-based clinical disease areas. These indicators are designed to encourage GPs to deliver high-quality care for patients with chronic conditions by measuring practice achievement against these indicators, and calculating payments based on the number of points achieved.

  3.4  As of April 2006 the QOF contained 1,000 points across 136 indicators and measures. There are currently 19 clinical areas consisting of 80 indicators. The vast majority of GP practices participate in the QOF, and a significant majority achieve a high degree of QOF compliance. In 2006-7, practices in England achieved an average 95.5% of the total 1,000 points available.[354] The QOF system is measured through the Quality Management Analysis System (QMAS), part of NHS Connecting for Health, which collects data on practice achievement against the QOF indicators and records changes in disease prevalence. We would welcome recognition by the Committee of the proactive way in which the profession has responded to the introduction of the QOF, changing clinical practice to reflect the priorities and incentives agreed. This progress should now be built on.

  3.5  The almost universal application of the QOF in practices across the country has had a significant impact on focusing GPs' attention on specific public health priorities. Evidence shows that QOF has driven the development of more systematic care across high prevalence disease areas leading to increased treatment rates and improved patient care for long term conditions. In the long term, we believe this will have a positive impact on health inequalities. We would welcome recognition by the Committee of the positive effect that QOF has had on standards of clinical practice.

  3.6  However, the prescriptive nature of the QOF has led to concerns that attention may be diverted from those conditions which are not included in the list of clinical indicators. Therefore we believe that it is vital that the QOF continues to evolve, encompassing new clinical indicators and incentivising continuous improvements in clinical practice. Concerns have been expressed that discussions about revisions to the QOF for April 2008 appear to have been delayed. We believe any move away from an annual review, leading to the inclusion of new indicators, would be extremely detrimental to ongoing efforts to improve clinical quality. We would welcome a recommendation by the Committee that discussions on revisions to the QOF should be prioritised and should not fall victim to any wider debates between the Government and that British Medical Association.

  3.7  The process for determining the inclusion of indicators in the QOF is currently complex and difficult to access for many patient groups. Although welcome improvements have been made to the transparency and accessibility of the expert review process, we believe further changes could be made.

  3.8  We welcome the fact that the expert submission process requires a demonstration of the impact that any indicator would have in tackling health inequalities. However, it is unclear what influence this has on the later negotiating stages. Inclusion in the QOF should be based on evidence, need and ability to deliver on national health priorities alone. We would welcome a recommendation from the Committee supporting this approach.

Using the Quality and Outcomes Framework to improve access

  3.9  There have been some suggestions that points should be taken from the clinical domain of the QOF and allocated towards extending GP opening hours. We would strongly urge against this approach:

—  The clinical domain has proved to be highly successful in incentivising better clinical care, based on high national minimum standards. As mentioned above, the QOF needs to continue to evolve, thereby encouraging a process of continuing improvement. Any reduction in the relative importance of the clinical domain would compromise this.

—  It is difficult to see how a reallocation of points could effectively incentivise large scale changes in extended access to GP services. Rather, it would reward those GPs who already have longer opening hours, without delivering a significant increase in accessibility in deprived areas and amongst hard to reach groups.

  3.10  We would therefore welcome a recommendation from the Committee that the relative importance of the clinical domains should be at least be maintained, as part of wider efforts to increase clinical excellence and the delivery of primary care according to national minimum standards.

Example—the exclusion of osteoporosis from the Quality and Outcomes Framework

  3.11  One disease area which we have been examining as a potential candidate for inclusion in the QOF is osteoporosis. Around one in two women and one in five men over the age of 50 will suffer from a bone fracture during their lifetime, and over 300,000 patients present to hospital each year with fragility fractures. The cost to the NHS for treating hip fracture alone amounts to approximately £2bn per year.[355]

  3.12  The human cost is also significant, with 80% of patients over 60 reporting that they would rather die than suffer the reduced quality of life that follows a hip fracture and transfer into social care[356]. Furthermore, around one third of hip fracture patients die prematurely within one year of suffering the fracture. In total there are approximately 3 million people in the UK either suffering from or at risk of osteoporosis, however the disease is currently not included in the list of QOF clinical indicators.

  3.13  The absence of osteoporosis in the QOF means that, despite the high levels of prevalence, the disease is not currently being treated as a priority in primary care. Only a small minority of fracture patients have been tested for osteoporosis and are on treatment to maintain and increase their bone density. As a consequence, evidence from primary care studies have shown that among women with a past history of fracture only 5% had undergone a bone density scan and less than 10% were receiving treatment for secondary fracture prevention.[357]

  3.14  Including a new clinical indicator linked to secondary prevention would incentivise GPs to refer patients who have suffered from a primary fragility fracture for a bone density scan and, if necessary, appropriate treatment. NICE has already recommended treatment for the secondary prevention of osteoporotic fracture in post-menopausal women.[358] Increasing the number of osteoporosis sufferers on treatment would be a major step in reducing the large number of fractures treated by the NHS each year, so reducing a major health inequality which affects older people. Projections show that unless greater interventions are made in the care of osteoporosis patients, hip fracture rates and commensurate care costs will double by 2050.[359]

  3.15  Inclusion of osteoporosis in the QOF is supported by the National Osteoporosis Society, the British Geriatrics Society, the British Orthopedic Association, The Royal College of Nursing and the Faculty of Public Health. A recent report commissioned by The NHS Information Centre based on a new clinical audit of fragility fracture patients also called for osteoporosis to be included in the QOF.

The importance of early diagnosis and management

  3.16  A major reason for health inequalities in conditions such as cancer is the later presentation and diagnosis of some groups within society. This can be attributed to lower levels of health literacy, poorer access to health services and lifestyle factors. Primary care services have a major role to play in addressing this, through:

—  Encouraging uptake of screening

—  Promoting greater awareness of signs, symptoms and risk factors

—  Ensuring accessibility to appropriate advice and services

—  Enabling GPs and other healthcare professionals to make prompt and accurate referrals for further investigation

  3.17  We therefore welcome the announcement of the National Awareness and Early Detection Initiative for cancer. Although focused on one disease area, we believe that this initiative may well produce lessons for other disease areas and therefore should be followed closely.

  3.18  Another example of the critical importance of early diagnosis is chronic kidney disease (CKD), where not only can early identification arrest disease progression, but can prevent costly "crash landing" into dialysis, which is associated with unnecessarily high mortality. CKD has recently been included in the QOF and early feedback suggests that rates of early identification have increased.

4.  THE EFFECTIVENESS OF PUBLIC HEALTH SERVICES AT REDUCING INEQUALITIES

  4.1  Reducing health inequalities should be a core function for public health services. However, there is some evidence that, when subject to financial pressures, PCTs have deprioritised longer term public health programmes in favour of achieving financial targets. One such example is obesity, where a range of interventions have been cut in some health economies, despite the increasing profile and prevalence of the condition.

  4.2  If implemented correctly, public health services can have a disproportionately beneficial long term effect on health inequalities. However, if a longer strategic approach is not taken, then there can be significant missed opportunities. An example of this is the diagnosis and treatment of hepatitis C. When diagnosed early, this condition can be effectively treated and cured. However, only a small proportion of the estimated patient population has been diagnosed and even fewer have been treated, meaning that England faces a potential public health time bomb.

  4.3  Although England has a Hepatitis C Action Plan which sets out the framework for planning and delivering services, including earlier diagnosis, evidence collected by the Hepatitis C Trust suggests that very few PCTs are implementing the Plan.[360] Few incentives or performance management mechanisms exist to ensure implementation and the time may now be right to revisit and revise the Plan in order to promote better implementation. We would welcome a recommendation from the Committee that the Department of Health should adopt a similar approach to that for cancer in developing strategies for less high profile conditions.

January 2008

353   DH, Cancer Reform Strategy, 2007. http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_081006 Back

354   The Information Centre http://www.ic.nhs.uk/statistics-and-data-collections/audits-and-performance/the-quality-and-outcomes-framework-qof/the-quality-and-outcomes-framework-qof-2006-07 Back

355   Taken from the National Osteoporosis Society Key Facts briefing paper. Back

356   The Blue Book, British Geriatrics Society, British Orthopaedic Association, September 2007. Back

357   The Blue Book, British Geriatrics Society, British Orthopaedic Association, September 2007. Back

358   NICE Technology Appraisal 87 (currently being reviewed on appeal). Back

359   The Blue Book, British Geriatrics Society, British Orthopaedic Association, September 2007. Back

360   The All Party Parliamentary Hepatology Group, A Matter of Chance, An Audit of Hepatitis C Healthcare in England, 2006 http://www.hepctrust.org.uk/NR/rdonlyres/92D12999-0D64-4028-8E15-1931A7368B21/0/AMatterOfChancePCTAuditofHepatitisCHealthcare.pdf Back