EXECUTIVE SUMMARY

—  Despite welcome progress in tackling mortality from cardiovascular disease (CVD), inequalities persist in access to effective proven medicines across the country. These must be addressed.

—  PCT's should adopt policies that seek to ensure that all patients who require treatment receive the right treatment for the right duration. In our experience some PCTs are using mechanisms such as incentive schemes and audits that focus on cost control and work against the pursuit of health equalities.

—  The Quality and Outcomes Framework (QoF) has been an effective mechanism for delivering change in GP clinical practice. However, conditions currently outside its scope, for example peripheral arterial disease (PAD)—a serious form of cardiovascular disease—may be less rigorously managed by comparison. The QoF needs to expand and evolve to keep pace with clinical knowledge and interventions.

—  The Government has made good progress towards its targets for tackling CVD, but there is no room for complacency.

INTRODUCTION

  1.  Bristol-Myers Squibb and sanofi-aventis welcome the opportunity to respond to the Health Select Committee's inquiry into the contribution of the NHS in reducing health inequalities.

  2.  As the manufacturers of Plavix (clopidogrel), a leading branded anti-platelet therapy used in the treatment and secondary prevention of cardiovascular disease (CVD), we are committed to playing a constructive role in helping communities tackle health inequalities, which continue to persist in cardiovascular disease. We will be limiting our response to our experience in this area, and to the following points of focus:

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

—  The influence of GP services on health inequalities, including how the Quality and Outcomes Framework and Practice-based Commissioning might be used to reduce health inequalities; and

—  Whether the Government is likely to meet its Public Services Agreement targets in respect of health inequalities.

  3.  Significant health inequalities are associated with CVD[361]. We therefore welcome this inquiry as an important opportunity to tackle health inequalities, particular in relation to CVD prevalence and outcomes.

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

  4.  Cardiovascular disease (CVD) is the number one killer in the United Kingdom and has been identified as a key target for health improvement. The main forms of cardiovascular disease (CVD) are heart attack, stroke and peripheral arterial disease (PAD). CVD causes four out of every ten deaths in the UK.[362] It is long term and life-threatening with a significant burden of care to the NHS.

  5.  The NHS has a key role to play in ensuring that health inequalities are reduced, not least because a reduction in the numbers of patients hospitalised with CVD morbidities would free up valuable NHS resource. There are many factors which contribute to health inequalities in CVD. Primary prevention strategies such as improving diet, exercise and reducing smoking rates are important if we are to succeed in reducing prevalence in the long term.

  6.  Advances in our knowledge of how to manage CVD also offer significant opportunities to reduce inequalities, both in terms of treatment and secondary prevention. Anti-platelets are one such intervention. Anti-platelets, such as Plavix or aspirin, are used to reduce the platelets forming a blood clot, reducing the risk of another heart attack or stroke occurring. They can be used alone, or in combination (in certain heart conditions). Anti-platelet therapies therefore have an important role to play in the immediate treatment of patients who have had a cardiovascular event, and in the secondary prevention of further events. Clear guidance from the National Institute for Health and Clinical Excellence (NICE) sets out the role that anti-platelets should play in managing CVD[363],[364].

  7.  However, we are concerned that inequalities remain in access to these proven therapies. Drawing on prescribing data from summer 2005 to 2006, unpublished research commissioned by our two companies demonstrated that despite the existence of national guidance on the use of anti-platelets, significant variations in prescribing remained. Overall there was more than a six-fold variation in the usage of anti-platelets between the highest and lowest prescribing PCTs. When "outriders" were removed (those in the 95th and 5th percentiles) a two-fold variation remained.

  8.  There were striking regional variations in usage of anti-platelets. Strategic Health Authorities (SHAs) do, of course, vary in terms of the health needs of the population they cover and it is right that they should tailor health services to reflect this. However people living in the South West were nearly twice as likely to be prescribed anti-platelets as Londoners. Likewise, there was a considerable variation in spend on coronary heart disease (CHD), with the South West spending more than 20% more on CHD than London. These inequalities could not be entirely explained by variations in CHD prevalence or deprivation.

  9.  Significant inequalities also exist in discharge practice. A national audit of 1400 patients with acute coronary syndromes during January-October 2005 found that the percentage of patients discharged on clopidogrel fell way below that recommended by NICE, with only 39-60% of eligible patients leaving hospital having commenced clopidogrel treatment.[365]

  10.  Some PCTs in England have in place incentive schemes to control the use of medicines or have conducted audits of the usage of particular medicines. It is important that NHS organisations seek to maximise value for money but very often these policies are driven by the need to reduce costs rather than ensure that the right patient gets the right medicine. Incentive schemes and audits focused primarily on cost-control risk compromising patient outcomes and safety, delivering a short term financial "fix" at the expense of failing to address the longer term underlying health needs of a population.

  11.  We believe that audits can be used effectively, but only when based on the following principles:

—  a proper assessment of individual patient clinical need and ongoing risk;

—  ensuring appropriate usage according to good practice evidence and national guidance; and

—  the patient making an informed choice

  12.  Unless equitable and appropriate access is given to these interventions, then there is a risk that health inequalities could actually widen: the health literate and most articulate people in society will continue to demand the best healthcare, while more disadvantaged groups will go without.

THE INFLUENCE OF GP SERVICES ON HEALTH INEQUALITIES, AND THE USE OF THE QUALITY AND OUTCOMES FRAMEWORK AND PRACTICE-BASED COMMISSIONING TO REDUCE HEALTH INEQUALITIES

  13.  CVD patients are, increasingly, living with their disease and managing their condition over the long term. They therefore rely on primary care services to provide them with effective interventions and support. The Quality and Outcomes Framework (QoF) has been an effective mechanism for ensuring that GPs identify and register patients with conditions singled out in the clinical domains, offer appropriate interventions to manage these conditions and monitor ongoing disease management. We believe that improving clinical practice should remain the focus for QoF, rather than seeking to use it to address other policy priorities, such as improving out of hours GP provision.

  14.  If the potential of the QoF to improve clinical practice is to be maximised, it needs to evolve, continuously incentivising clinical excellence. We therefore believe that the QoF needs to be expanded and built upon, addressing new clinical areas and keeping pace with increasing clinical knowledge about effective interventions. Anomalies still exist in the QoF with regard to the diseases which are included and those which are not, and this can lead to less rigorous management of those outside its scope.

  15.  For example, CVD can present as a multivascular disease, taking three main forms—CHD, stroke and peripheral arterial disease (PAD)—but only CHD and stroke are acknowledged in the current QoF. PAD is a significant omission. Using European data, it can be estimated that there are at least 720,000 people with symptomatic PAD in the UK (6% of the over 60 UK population of 13m).[366] Symptomatic PAD carries a 30% risk of death within five years, rising to almost 50% within 10 years, mainly due to heart attack (60%) and stroke (12%).[367] Results of a multi-national registry show that PAD has a one-year cardiovascular risk (that is, a risk of cardiovascular death, stroke, heart attack or hospitalisation) which, at 18.2%, is significantly higher than that of CHD (13.3%).[368]

  16.  Despite this significant cardiovascular morbidity and mortality PAD is under-diagnosed and under-managed. If the Government is to reach its targets for Coronary Heart Disease (CHD) management in the UK, which forms one of it's main health aspirations, PAD should be recognised as a significant health burden and managed with the same vigour as CHD. This should include an expansion or reallocation of clinical domain points to include the registration and management of symptomatic PAD.

  17.  We would welcome a recommendation from the Committee that NHS Employers and the British Medical association, as the negotiators of the QoF, should prioritise reaching an early agreement on evolving those indicators included in the clinical domain, so incentivising further improvements in the management of conditions such as PAD, helping to tackle health inequalities.

WHETHER THE GOVERNMENT IS LIKELY TO MEET ITS PUBLIC SERVICE AGREEMENT TARGETS IN RESPECT OF HEALTH INEQUALITIES

  18.  Welcome progress has been made on tackling CVD. If this continues, the Government is on track to meet its two PSA targets relating to CVD:

—  to reduce deaths from CHD, stroke and related diseases in people under 75 by at least two fifths by 2010

—  to reduce the inequalities gap in premature death rates from CVD between the areas with the worst health and deprivation indicators and the rest of the population as a whole by 40%

  19.  Figures for England released by the Department of Health in September 2006 indicate that the death rates for people under 75 from CVD have reduced by 35.9% since 1996. This amounts to almost 150,000 lives being saved since 1996—a number similar to the entire population of Blackpool.[369]

  20.  However there is no room for complacency. Inequalities in CVD persist, and the target is for a narrowing of the gap rather than an eradication of it. We are keen to see that the welcome progress on CVD does not stop when the PSA deadlines are reached, and to work in partnership with the NHS and others to see that inequalities continue to reduce.

January 2008

362   Office for National Statistics; General Register Office, Edinburgh; General Register Office, Northern Ireland. Back

363   NICE Technology Appraisal TA080: Clopidogrel in the treatment of non-ST-segment-elevation acute coronary syndrome. July 2004. http://www.nice.org.uk/page.aspx?o=TA80 Back

364   NICE Technology Appraisal TA090: Clopidogrel and dipyridamole for the prevention of artherosclerotic events. MaŸy 2005. http://www.nice.nhs.uk/guidance/TA90 (+National Institute for Clinical Excellence clarification: Available at: http://www.nice.org.uk/page.aspx?o=274726) Back

365   Innovex Health Management Solutions. Audit of Clopidogrel Prescribing in Acute Coronary Syndromes (ACS). Unpublished, but available on request. Back

366   Norgren L, Hiatt WR et al. Inter-Society Consensus for the Management of Peripheral Arterial Disease (TASC II). Eur J Vasc Surg Vol 33, Supplement 1, 2007. Back

367   Tierney S, Fennessy F, Bouchier-Hayes D. Secondary prevention of peripheral vascular disease. Br Med J 2000; 320: 1262-5. Back

368   Steg PG, Bhatt DL, Wilson, PWF et al. Reduction of Atherothrombosis for Continued Health (REACH) Registry Results: 1-Year Cardiovascular Event Rates in a Global Contemporary Registry of over 68,000 outpatients with Atherothrombosis. JACC 2006;47(4):168A. Back

369   Department of Health Press Release: Mortality rates from heart disease and cancer improve. 27 September 2006. Available at: http://www.gnn.gov.uk/environment/fullDetail.asp?ReleaseID=229973&NewsAreaID=2&NavigatedFromDepartment=False Back