Healthy outlook for UK

Graham Lampard met Andrew Curl, deputy director of the ABPI, to discuss the wellbeing of the UK pharma industry

The UK pharmaceutical industry provides the nation's medicines to the National Health Service (NHS) at a daily cost of just 29p per person – less than a third of what we spend on alcohol1 (see figure 1). In real terms, NHS medicine prices are 15% lower than 10 years ago, despite the rush to new, usually more expensive, treatments.

The UK continues to be a premier base for pharmaceutical r&d and manufacturing, with 40% of all r&d in the UK coming from the pharmaceutical industry (table 1). Last year the UK trade surplus in pharmaceuticals soared by 21% to £2.866bn (€4.589bn), and exports rose by 27% to £9.259bn(€14.825bn) (figure 2).

This looks set to continue,according to Andrew Curl, deputy director of the Association of the British Pharmaceutical Industry (ABPI). He highlighted the constructive relationship with government, in which both sides are building a 'true partnership', as one of the reasons for the on-going expansion.

This has been achieved mainly through the pharmaceutical industry competitiveness task force (PICTF) process, 'which will lay down a framework where government and industry can talk together about difficulties that occur.' The PICTF report was a result of year's work, involving more than 150 people from government, industry and academia. It highlighted 69 areas for action, 'and industry and government officials have worked together to implement an ambitious and comprehensive action plan'.

Curl is pleased the government is committed to the industry continuing to expand in the UK, demonstrated through initiatives such as the National Service Frameworks (NSFs) 'The setting up of NSFs, with government money, means that more patients are getting more access to better treatment.'

drug expense

There are seven NSFs, in the areas of mental health, coronary heart disease, older people, diabetes, children's services, renal services, and long-term conditions. The first three have already been written, while the others are being developed. They are intended to ensure a uniform standard of care to NHS patients, which, if they are achieved, the government believes will improve the health of the nation. 'We have been involved from the beginning. They are an excellent example of the tangible role that industry can play with government,' Curl said.

He thought it was also encouraging that the secretary of state for health, Alan Milburn, said that if we are spending more than we expected on drugs, that's probably good as it means we are keeping patients out of hospital in the long term. 'That kind of attitude, is very welcome because it shows that the value of the industry is really recognised.' Curl commented. 'I can't emphasise strongly enough the constructive relationship the industry has with government, through the joint PICTF process we have set up.'

Although the UK pharma industry is in a very healthy state, the ABPI has concerns about a number of issues. One is the grey or the parallel trade market. 'Clearly, parallel trade is legal, but it costs the UK industry £1bn (€1.6bn) per year.' Of that £1bn, the government gets very little, with most of the profits going to those who import the medicines, who have invested in very little other than a white van and some warehousing.

'We think that is unfair – the industry is losing, as is the country. The question of what can be done is complex. The reimbursement system for pharmacies actively encourages retail pharmacists to seek out parallel trade, because of the clawback mechanism, which assumes that a certain percentage of the business comes from that trade.

'That can't be right, because although they may not wish to, they have to do so to get some economic compensation.' The ABPI believe that the system should be changed: 'If parallel trade continues, there should be some kind of readjustment that means all the stakeholders benefit.' However, given that it is a perfectly legal trade, it is an area that is unlikely to see much change.

animal rights

Another area where the government is receiving praise is for its handling of the animal rights issue in the pharma industry. 'R&d expenditure is running at £8m (€12.8m) a day and we welcome the support government has given industry in terms of tackling the animal activists issue.

'While we have no evidence that any companies have blocked investment decisions based on activists' activities, it certainly has a deleterious effect on individuals' lives, where they have been continually harassed.

'We and the government absolutely condemn that and it is heartening to see the courts, and upcoming legislation, take a similar view.'

A worrying statistic, said Curl, is that compared with other countries Britain spends the lowest share of its medicines budget on new drugs: 16%, compared with 25% in Germany, while over a third of the US's medicines budget is spent on new drugs. There are a number of reasons for this, Curl believes: 'First, the UK prescribers are generally conservative in their ways. They know about modern drugs, but they tend to stick with regimes that have served their purposes over the years. Recently though some things have exaggerated that – such as NICE.'

Although broadly supportive of the 'excellent aims' of the National Institute of Clinical Excellence, Curl complained that while the NICE panel is reviewing drugs, prescribers don't use them. 'It's what we call "NICEblight": a product is on the market, it's been registered and approved, but prescribers don't use it until they hear the outcome of the NICE review.'

affordable basis

There are also concerns about the appeals process: if a product is not recommended by NICE, the appeal is chaired by the same person. But 'if NICE can do its part and remove postcode prescribing, then it has our strong support,' said Curl, 'because we are in the business of making products available to patients on an affordable basis.'

The final obstacle to the use of new medicines is budgets. The newer treatments are usually more expensive, and health authorities are constrained by budgets. 'If government is going to encourage NSFs, then it has got to make the funds available to ensure those decisions can be implemented.' Although the government maintains that the money is already there for new products, he said, the ABPI would like to see extra money ploughed into making new products more easily available.

'We don't believe that [new] drugs are being prescribed in the volumes that bodies, such as NICE, expected them to be,' said Curl. According to the ABPI, NICE was expecting additional expenditure on medicines to be about £93m (€149m), but the ABPI calculated that it was actually £32m (€51m). Curl suggested the discrepancy was again due to conservatism in prescribing the new drugs, even after they had been approved by NICE. 'They [the prescribers] didn't feel they had the funds to prescribe the drug at the kind of level NICE had been expecting.'

The Wanless report confirmed the UK's position as 'a late and slow adaptor of medical technology'. Curl thought this a reasonable comment and said that to improve the situation: 'the government needs to take the lead by saying new funds are available, continuing to encourage NSFs, and the use of NICE as an organisation that aims to end the curse of postcode prescibing.

report recommendations

'If we can give the NSFs teeth, and change the way prescriptions are written and how the screening of patients is conducted, and if NICE can deliver new technologies quickly, then the government will have done its job. But it needs to arrange it budgets in such a way that it can convert Wanless's recommendations into real activity,' Curl asserted.

'And this is a report that must be actioned. The government has said: "We're raising taxation because we want to implement it". We welcome the report and we want to work with the government to convert those aspirations into reality.'

However, research by the National Institute of Economic and Social Research suggested that there is a £15bn (€24bn) black hole in Treasury arithmetic, and added that: 'if, in the longer term, the government wanted to increase spending on the NHS to levels envisage by the Wanless report, Gordon Brown, the UK Chancellor, would have to sanction even more punitive tax rises.'2

A quote from a document by the department of health reads: 'The era of the patient as a passive recipient of care is changing and being replaced…with one in which patients are empowered with information and contribute ideas to…their treatment and care.'

It signals a change in the roles played by doctors, pharmacists, patients and the pharmaceutical industry. A number of issues arise from this.

Curl said: 'The informed patient is a patient who has found out more about the illness he is suffering from. It's much more a two-way conversation; clearly the doctor remains the prime source of information, although the internet is also a good source of information.

access reduced

'But ironically the drugs industry is unable to post on websites the treatments available. So anybody can set up a website about a particular treatment except the drug industry, which spends all the time and money researching that treatment.' This is obviously a situation the industry feels strongly about, but to alter it would take a change in legislation. 'What we are not looking for is direct-to-consumer advertising, which isn't appropriate. What we are looking for is access for patients to data sources that are reliable and that come from companies that spend most time developing the regime.

'Patients these days are much more interested in the management of their treatment, rather than just going to the doctors who says: "Take this two or three times a day",' emphasised Curl.

Another part of the equation is whether more drugs should be available otc. The question has been raised in the US, and the ABPI feels that it is something to support in the UK, but with two caveats: first, patient safety, which should always be paramount; and second, the conversion should be at the instigation of the drug licence holder. The government is taking this area seriously, with Lord Hunt announcing that a working group is to be set up to look at this question.

Although it should make drugs more easily available, perversely it may have the opposite effect. Common drug regimes will be more expensive for patients, because currently around 85% of prescription drugs are dispensed free of charge (see table 2). Higher costs almost inevitably mean a reduction in access to the drug.

changing role

Finally, there is the changing role of pharmacists. Curl said: 'The government is looking at ways of bringing in new or supplementary prescribers, and here the role of pharmacists will clearly be important, as a manager of long term treatments – repeat prescriptions – which will reduce the time doctors have to spend on this area. It is an initiative that the industry welcomes because it gives us an opportunity to build on the relationship we have with pharmacists.'