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Vol 53 | No 6 | June 2015 

62 DTB Select: 6 - June 2015 65 Correction: Drugs for the doctor's bag: 1-adults

66 Challenges in managing drooling in children

69 Drugs for the doctor's bag: 2–children

The NHS medicines bill: running out of control? Every year NHS organisations painstakingly estimate the likely expenditure on medicines in order to establish a realistic drugs budget to meet the needs of their patients. Predicting such expenditure involves extrapolating from current prescribing patterns and adjusting for factors that increase costs (e.g. changes in demographics, the requirement to fund nationally approved medicines, the launch of new medicines) as well as those factors that help to reduce costs (e.g. medicines coming off patent, availability of biosimilars, initiatives to reduce wastage of medicines).1 In 2013/2014, the NHS across the UK spent over £15 billion on medicines in primary and secondary care. In England, the drugs bill increased by 7.6% over the previous year compared with an increase of 2.6% in the overall NHS budget.2,3 It is clear that medicines represent an important area of financial risk that has an impact on overall health service delivery. Consequently, there is an expectation that this risk should be quantified and managed. Some national and local schemes have helped to offset the rise in the drugs bill. For example, the voluntary Pharmaceutical Price Regulatory Scheme (PPRS) sets agreed limits on growth in the overall cost of some branded medicines purchased by the NHS;4 prescribing initiatives have been developed to help maintain or improve quality and improve value;5 individual NHS organisations have introduced local restrictions on the use of some drugs on the grounds of safety, efficacy or cost-effectiveness (with the inevitable risk of postcode prescribing).6,7 However, a number of other factors, over which NHS organisations have little control, make the task of predicting and managing expenditure on medicines

particularly challenging. The prices of some generic medicines have increased significantly—such problems become especially difficult to manage when there is a single manufacturer. For example, the price rise for phenytoin capsules was estimated to cost the NHS £43 million per year.8 In addition, there has been an increasingly robust approach to extending and defending patents on branded medicines to delay the launch of generic versions for as long as possible. Over the last few years the patents on a few key medicines almost universally used in adults have been extended through successful application for a paediatric investigation plan, thus delaying the launch of generic competitors by 6 months. More recently, the patent for pregabalin’s use for neuropathic pain has been vigorously defended.9 Other national schemes focus on increasing access to new medicines through statutory regulation (while attempts to rationalise the use of appraised medicines seem to be discouraged).10 Furthermore, there are no nationally mandated disinvestment policies for medicines that are not cost-effective. There is no requirement for Market Authorisation holders to demonstrate that the benefits seen in a few thousand patients in research trials are actually delivered in clinical practice, and the pricing structure for generic medicines is largely subject to the whims of a free market. Unless there is a coordinated national approach to addressing such conflicting issues, there is a risk that expenditure on medicines will take an ever larger and unplanned slice of the NHS budget at the expense of other services without providing additional clinical benefit to patients.

  1. NHS England, 2013. NHS allocations for 2013/14 [online]. Available: http://www.england.nhs.uk/allocations-2013-14 [Accessed 20 May 2015].   2. UK Medicines Information, 2014. Prescribing outlook-new medicines [online]. Available: http://www.ukmi.nhs.uk/filestore/ukmianp/2014PrescribingOutlook-NewMedicines2014FINAL.pdf [Accessed 20 May 2015].   3. Health and Social Care Information Centre, 2014. Hospital prescribing: England 2013-14 [online]. Available: http://www.hscic.gov.uk/catalogue/PUB15883/hosp-pres-eng-201314-rep. pdf [Accessed 20 May 2015].   4. Department of Health, Association of the British Pharmaceutical Industry, 2013. The Pharmaceutical Price Regulation Scheme 2014 [online]. Available: https://www.gov.uk/ government/uploads/system/uploads/attachment_data/file/282523/Pharmaceutical_Price_Regulation.pdf [Accessed 20 May 2015].   5. National Institute for Health and Care Excellence, 2013. Key therapeutic topics – medicines management options for local implementation: interim process statement [online]. Available: http://www.nice.org.uk/article/pmg7/chapter/1%20introduction#introduction-to-interim-process-statement [Accessed 20 May 2015].   6. NHS Stockport Clinical Commissioning Group, 2015. Black and grey list [online]. Available: http://stockportccg.org/gp-members-area/medicines-management/black-grey-list/ [Accessed 20 May 2015].   7. Brighton and Hove Clinical Commissioning Group, 2015. Appendix 3 blacklist [online]. Available: http://www.staff.brightonandhoveccg.nhs.uk/sites/default/files/resources/a_3_ blacklist_apc_rv_nov_14.pdf [Accessed 20 May 2015].   8. Pulse, 2012. Price of anti-epilepsy drug rockets [online]. Available: http://www.pulsetoday.co.uk/commissioning/commissioning-topics/prescribing/price-of-anti-epilepsy-drugrockets/20000936.article#.VUtFevlVhBc [Accessed 20 May 2015].   9. What a pain. DTB 2015; 53: 49. 10. National Institute for Health and Care Excellence, 2015. Achieving and demonstrating compliance with NICE TA and HST guidance [online]. Available: https://www.nice.org.uk/ Media/Default/About/what-we-do/NICE-guidance/NICE-technology-appraisals/Frequently-asked-questions-on-NICE-compliance.pdf [Accessed 20 May 2015].

DOI: 10.1136/dtb.2015.6.0329

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The NHS medicines bill: running out of control? DTB 2015 53: 61 originally published online June 4, 2015

doi: 10.1136/dtb.2015.6.0329 Updated information and services can be found at: http://dtb.bmj.com/content/53/6/61

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The NHS medicines bill: running out of control?

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