EXECUTIVE SUMMARY

  Pfizer welcomes this opportunity to submit evidence to the Health Select Committee's inquiry into the contribution of the NHS to reducing Health Inequalities.

  Pfizer believes that clinicians should have the right to prescribe whichever treatment they feel will be most efficacious and beneficial to each individual patient and that the NHS should provide the support, finance and infrastructure to enable this.

  This is in line with National Institute for Health and Clinical Excellence (NICE) and Department of Health (DH) national guidance, but at local level, this guidance is not always followed, for a variety of reasons, leading to health inequalities in the provision of medicines to patients.

  As a consequence of our experience in dealing with health inequalities in treatment both in the UK and elsewhere in the world, Pfizer believes that the NHS can achieve a reduction in health inequalities by addressing two key issues:

1.  that of differential access to medicines and services across the UK, which can be rectified through reform of the current Health Technology Assessment (HTA) process and local level NHS reform to eliminate inequalities including "postcode prescribing".

2.  the issue of unequal access to lifestyle and healthcare information. In addressing this issue, the NHS should take into account the huge and largely untapped potential that closer partnership with the pharmaceutical industry holds for the provision of information to patients.

  Pfizer is already working successfully with the NHS to eliminate health inequalities at individual Primary Care Trust (PCT) level and will welcome the opportunity to work much more closely with the NHS to achieve the same results on a UK-wide basis.

1.  SITUATION

  1.1  Pfizer's core contribution to reducing health inequalities in the UK is through the medicines we produce. Many of these medicines treat diseases that are caused by health inequalities, yet in certain geographies and circumstances, patients are denied access to them, leading to further health inequalities.

  1.2  Cancer medicines alone now comprise around 30% of Pfizer's product portfolio, alongside products for use in therapy areas including respiratory and cardiovascular disease.

  1.3  However, our engagement alongside healthcare providers in the UK and in healthcare services across the world has given us insight into world-class patient relationships that facilitate treatment in primary and secondary care.

  1.4  Likewise, the evolution and diversification of our company and industry into the fields of disease management and the psychological needs of patients, as well as investigation of socio-economic mapping and diagnostic tools, is reflective of the manner in which we believe the NHS should address health inequalities in the future and demonstrates the potential for partnership with pharmaceutical companies.

  1.5  In our view, there are two key points around health inequalities that the NHS in the UK should and can address:

1.5.1.  Health inequalities, as they relate to the NHS, are frequently created and exacerbated by differential access to medicines and services.

1.5.2.  Asymmetrical access to healthcare information has the same negative impact, often due to differing demands on NHS resources at local level. Addressing this issue through a partnership approach with industry has enormous potential and the NHS needs to consider how this can be achieved without diminishing its independence and public service ethos.

2.  ACCESS TO MEDICINES AND SERVICES

  2.1.  Despite government efforts to eliminate "postcode prescribing", it still exists for a number of different reasons, denying patients in specific geographical locations access to medicines.

  2.2  One example of this is devolution, which has led to different appraisal bodies deciding which medicines to make available in each country, based on very different HTA criteria. This lack of standardisation across the UK has even led to people moving across borders in order to obtain treatment for conditions that they cannot receive in their home country.

  2.3  There is therefore a clear need for reform to address this issue so that the Scottish Medicines Consortium (SMC) and NICE in England, Wales and Northern Ireland standardise guidance and HTA methodologies.

  2.4  However, HTAs themselves are at the heart of the postcode prescribing problem, a fact that has been recognised in some of the recommendations of the House of Commons Health Committee (HSC) investigation into NICE, published on 09th January 2008.

  2.5  The HSC call for the creation of an independent commission to review thresholds for Quality Adjusted Life Years (QALYs) is a potentially positive step. However, we believe that any reduction in the QALY threshold, whether in the context of a brief initial assessment (as recommended in the HSC report) or a full assessment, can only exacerbate the existing health inequalities situation by denying yet more patients access to the clinically proven medicines that they need.

  2.6  Furthermore, we believe that such an independent commission should go beyond the recommended composition of NICE, DH and PCTs to include industry, academia and patients. In addition, this group should have a wider remit, to review and negotiate the joint development of models and approaches. This should include work to:

2.6.1.  broaden the approach taken to calculating the value of medicines, including the HSCs recommendation to include factors such as the impact on patients and caregivers

2.6.2.  understand how a flexible approach to, and broader thresholds for, Quality Adjusted Life Years (QALY) might be introduced for certain priority disease areas and accept the limitations of using QALYs to measure the value of medicines

2.6.3.  ensure that the appeals process is fully transparent and independently overseen

2.6.4.  ensure that assessment methodologies and assumptions etc. are standardised

2.6.5.  further research is required to develop more robust, inclusive and transparent methodologies for valuing medicines. These need to acknowledge the variations in patient response to medicines and the limitations of applying population level models to individuals.

  2.7  The HSC findings also noted the differences in thresholds and preparedness to use newer technologies between PCTs. This is a familiar picture in England and stems from budgetary issues, with two key areas for concern being readily identifiable:

2.7.1.  Some PCTs arbitrarily decide to deny patients certain medications because of their own budget priorities, going against NICE and DH guidelines and thus creating geographical inequalities. As a direct example of this, Pfizer has a smoking cessation product that was approved by NICE more than six months ago and which is still being either refused to patients or only made available as a second or third line treatment in some twenty PCTs across the country.

2.7.2.  Clear health inequality is generated by differential approaches to exceptional case review at PCT level. The most often cited examples concern oncology treatments, when Cancer Networks receive different levels of support and funding from PCTs regarding a particular medicine. As has been recognised by the HSC, this can be dependent on the evaluation criteria and thresholds used by individual PCTs to fit with their own budget availability and which differ from the process and thresholds used by NICE. This leads to situations where some patients can receive one form of treatment as standard when others who live in close proximity will be denied access to clinically effective medicines and have to apply for them on a case-by-case basis, with no guarantee of approval.

  2.8  We believe there must therefore be clear and common standards in every PCT for exceptional case review to avoid postcode driven differences and a willingness on the part of the PCT to conduct this conversation in public. There must also be a common standard across PCTs to reach a decision within a maximum of 2 weeks, since many of the patients caught in this "NICE blight" have terminal illness or time sensitive disease (eg Age-related Macular Degeneration).

  2.9  As noted above, lack of available budget is the decisive factor at PCT level. This is despite the fact that while QALY thresholds have been static since 1999, in the intervening period, the NHS annual budget has more than doubled, from £40 billion to £90 billion, meaning that funds for medicines ought to be available.

  2.10  The issue is therefore one of forward planning, to proactively allocate budgets in readiness for future need, thus eliminating "postcode prescribing" and the resultant health inequalities. We therefore welcome the HSC recommendation that a change of language should take place where NICE HTAs requiring mandatory funding should be renamed "NICE Directives" in order to avoid confusion and ambiguity.

  This state of preparedness can be achieved through closer engagement between the NHS and the pharmaceutical industry in "horizon planning" and medium-term resource allocation to allow adequate provision for new licensed medicines awaiting HTA and for those with a positive HTA decision in-year. This could be achieved through introducing a central fund held at Strategic Health Authority (SHA) level, to be allocated specifically for the purpose of providing these new treatments on a planned rollout as new medicines became available.

  2.11  The HSC also recommended that there should be better assessment of the level of uptake of NICE HTA recommendations and we believe PCTs could be measured against one another by the Care Quality Commission or Monitor on uptake and diffusion as well as against comparator countries via an "innovation index".

  2.12  An additional policy device that we believe should be used to encourage compliance within the NHS and thus eliminate inequalities in access to medicines is the introduction of uptake incentives at a local level for medicines (or other technologies) that have had a positive appraisal. This incentivisation could be achieved through the Quality and Outcomes Framework (QOF) for GPs and through the introduction of a similar system for medicines (such as chemotherapy) that are only prescribed by hospital consultants.

3.  ACCESS TO INFORMATION AND WORKING IN PARTNERSHIP WITH THE PHARMACEUTICAL INDUSTRY

  3.1  A key to addressing health inequalities must be the education and empowerment of people, combined with the delivery and availability of the necessary resources—both educational and medical—which are the essential prerequisite to receiving appropriate care.

  3.2  The NHS has a vital role to play in an upweighted and ongoing education programme aimed at groups that have traditionally been hard-to-reach, often as a result of factors arising from deprivation.

  3.3  In conveying accurate information to patients, we feel that there is a valuable, untapped resource readily available within the pharmaceutical industry and Pfizer will welcome greater engagement with the NHS at all levels, from PCTs upwards, in order to help achieve this.

  3.4  With both a commercial interest in producing prescription medicines for use by those patients who most need them and a genuine commitment to improving patient health, Pfizer takes the issue of health inequalities very seriously and has a proven pedigree in working in this field.

  3.5  The Pfizer UK Foundation was established by Pfizer in 2005 to address health inequalities across the UK arising from social, economic, cultural and demographic factors. It supports community based projects that tackle health inequalities and which fall outside core NHS statutory funding. The aim is to support projects providing tailored, innovative, modest and local solutions to needs defined by local healthcare experts, social care experts, community groups and charities and can also involve working with innovative thinkers in primary and secondary care. To date the Foundation has donated £2,894,079 (£1 million a year) to 121 projects across the UK, with an estimated 259,137 beneficiaries.

  3.6  Our experience of direct engagement at PCT level through other areas of our business, as demonstrated by the two examples below, reveals the potential for effective partnership between industry and the NHS in addressing health inequalities across the UK in the future. Ten Pfizer Local Market Managers (LMMs) are based locally around NHS Strategic Health Authorities boundaries with a specific role to identify health inequalities. They carry out regional strategic assessment which include analysis of population demography's and assessment of health needs across this population. Wherever possible, Pfizer LMMs work in collaboration or partnership with PCTs and Health Care Professionals locally to address these inequalities by providing additional expertise and assistance to reach patients. It must be stressed that the Pfizer LMM input does not in any way promote products—instead, the focus is on supporting disease awareness activities and marketing support.

  3.7  In April 2006, Birmingham East and North PCT, UK Pfizer Health Solutions and NHS Direct launched a joint partnership initiative, Birmingham OwnHealthð®ñ, an innovative nurse-led care management service delivered over the telephone to support up to 2000 patients with long-term conditions in Birmingham. The focus is on changing patient behaviour in the disease areas of diabetes, coronary heart disease and heart failure, all of which are frequently associated with health inequalities, while encouraging greater self care.

  The early indications from the Birmingham OwnHealthð®ñ service suggest some significant trends concerning community medical resource access by Birmingham OwnHealthð®ñ project participants over the past year, most notably:

—  A 48% reduction in hospital admissions

—  A 53% reduction in A&E visits

—  A 32% reduction in GP visits[329]

  Other initiatives to improve healthcare in the region may have had an influence on these results, so we are already actively undertaking comparative analysis, cost effectiveness and root cause analysis to see whether these improvements can be translated into more effective use of healthcare resources. We hope to be able to publish the results of this analysis in mid 2008.

  3.8  Another example of successful collaboration at PCT level is the Town & Bridge Project in Ipswich, where the council and PCT has set up a group called the One Ipswich initiative. The Town and Bridge wards have a higher death rate than the rest of Suffolk (up to 75% higher) and the One Ipswich group was established to reach out to these two wards. A major part of this initiative has been around smoking cessation, where the PCT and local Stop Smoking Service identified the need for additional resource to engage hard-to-reach smokers. Working in partnership with them, Pfizer investigated reasons for lack of uptake of smoking cessation services in these two wards and identified logistical and transport difficulties as obstacles to accessing the stop-smoking-services. As a result, of this partnership, the SSS, PCT and the Town and Bridge project manager established three new clinics in the community in October 2007, using experts such as nutritionalists and exercise specialists to assist patients and create a fully informed and incentivised "willing quitter". Pfizer added marketing expertise to support this initiative, which included utilising interior and exterior bus advertising on those routes passing through the Town and Bridge Wards that serviced the new clinics and placing posters and materials at Ipswich Town football club matches. Results are currently being evaluated, but the principle of ensuring that patients can access the services they need is one that must be applied across the board to target hard-to-reach population groups.

RECOMMENDATIONS

—  Reform and standardisation of Health Technology Assessments by NICE and the SMC, including greater transparency, flexibility and the establishment of an independent commission to review and negotiate the joint development of models and approaches.

—  "Horizon planning" in partnership with industry and the establishment of a fund held at SHA level to be used for new licensed medicines awaiting HTA and for those with a positive HTA decision in-year.

—  The establishment of clear and common standards in every PCT for exceptional case review and to ensure decisions are made within a two week period.

—  The introduction of uptake incentives at a local level for medicines (or other technologies) that have had a positive appraisal, through QOF for GPs and a similar system for other groups such as consultants.

—  Partnership between the NHS and the pharmaceutical industry at national rather than local level to achieve the best possible outcomes for patients, combining industry resources and expertise with the experience and professionalism of the NHS at educational and programme implementation levels.

January 2008