National Health Service Budget Research Articles

Optimizing Treatment of Schizophrenia: Clinical and Economical Potential for Patient Switching to Long‑Acting Injectables

INTRODUCTION: Long-acting injectable antipsychotics (LAIs), due to a lower frequency of administration, could address the well-established challenge of non-adherence to oral ones. We conducted a Network Meta-Analysis (NMA) to assess the relationship between administration frequency and effectiveness. The recent introduction of a semi-annual paliperidone palmitate formulation, along with the arrival of monthly paliperidone generics, could emphasize LAI’s advantages. Aim of this paper is to present the results derived from an updated version of our previous NMA. These results are used to fuel a budget impact model built to evaluate the economic implications of optimizing dosing intervals.METHODS: We compare the current distribution of patients among available LAI active substances and dosing frequencies with an optimized scenario. In this scenario, 20% of patients are switched to the next permitted regimen with a longer inter-dosing interval. Drug acquisition costs and relapse management costs are taken into account over a one-year simulation period; these last items are estimated by means of the event rates obtained from the updated meta-analysis. The optimized scenario incorporates the reduced cost resulting from the expiration of patents.RESULTS: Throughout the analysis, a total of 11,600 patients were able to switch from shorter to longer dosing intervals, leading to an overall optimization of quality of care. The greater expenditure incurred by the Italian National Health Service (NHS) in the acquisition of newer and longer-lasting drugs is offset by savings associated with the arrival of generics of monthly paliperidone palmitate and the shift toward less-relapsing regimens. The net impact on the NHS budget is a saving of more than 19 million Euros.CONCLUSION: This economic saving has the potential to initiate a virtuous process: it could be reinvested to fund a further shift from oral daily therapies, which are less expensive but marked by poor compliance, to LAIs. According to our simulation, nearly 40 thousand patients could undergo this transition, without additional expenses for the NHS.

THE BURGEONING BURDEN OF PERINATAL MENTAL HEALTH IN LOWER MIDDLE-INCOME COUNTRIES

THE BURGEONING BURDEN OF PERINATAL MENTAL HEALTH IN LOWER MIDDLE-INCOME COUNTRIES

New development: From blanket coverage to patchwork quilt—rethinking organizational responses to fraud in the National Health Service in England

IMPACT This article will be of value to those working across the National Health Service (NHS) and particularly to those engaged in counter fraud activities across the public sector. As well as having national value, this article will be of international relevance as it speaks to the responsible guardianship of public funds. This article evidences the ways in which counter fraud services across the NHS in England are disjointed and some of the causes for such disjointedness. Official reports estimate that at least £1.2 billion, approximately 1% of the NHS budget, is annually lost to fraud. At a time when the NHS is facing unprecedented demand on its resources due to austerity policies, Brexit and the global pandemic, and with no clear indication of significant additional investment, any loss of NHS funds could have significant impact on patient care and so a better understanding of counter fraud responses in the NHS is potentially pivotal to future responsible handling of public money.

Related variations: A novel approach for detecting patterns of regional variations in healthcare utilisation rates.

Regional variations in healthcare utilisation rates are ubiquitous and persistent. In settings where an aggregate national health service budget is allocated primarily on a per capita basis, little regional variation in total healthcare utilisation rates will be observed. However, for specific treatments, large variations in utilisation rates are observed, iymplying a substitution effect at some point in service delivery. The current paper investigates the extent to which this substitution effect occurs within or between specialties, particularly distinguishing between emergency versus elective care. We used data from Statistics Norway and the Norwegian Patient Registry on eight somatic surgeries for all patients treated from 2010 to 2015. We calculated Diagnosis-Related Group (DRG) -weight per capita in 19 hospital regions. We applied principal component analysis (PCA) to demonstrate patterns in DRG-weight, annual relative changes in DRG-weight, and DRG-weight production for elective care. We show that treatments with similar characteristics cluster within regions. Treatment frequency explains 29% of the total variation in treatment rates. In a dynamic model, treatments with a high degree of emergency care are negatively correlated with treatments with a high degree of elective care. Furthermore, when considering only elective care treatments, the substitution effect occurs between specialties and explains 49% of the variation. When designing policies aimed at reducing regional variations in healthcare utilisation, a distinction between elective and emergency care as well as substitution effects need to be considered.

Budget impact analysis of a machine learning algorithm to predict high risk of atrial fibrillation among primary care patients.

We investigated whether the use of an atrial fibrillation (AF) risk prediction algorithm could improve AF detection compared with opportunistic screening in primary care and assessed the associated budget impact. Eligible patients were registered with a general practice in UK, aged 65 years or older in 2018/19, and had complete data for weight, height, body mass index, and systolic and diastolic blood pressure recorded within 1 year. Three screening scenarios were assessed: (i) opportunistic screening and diagnosis (standard care); (ii) standard care replaced by the use of the algorithm; and (iii) combined use of standard care and the algorithm. The analysis considered a 3-year time horizon, and the budget impact for the National Health Service (NHS) costs alone or with personal social services (PSS) costs. Scenario 1 would identify 79 410 new AF cases (detection gap reduced by 22%). Scenario 2 would identify 70 916 (gap reduced by 19%) and Scenario 3 would identify 99 267 new cases (gap reduction 27%). These rates translate into 2639 strokes being prevented in Scenario 1, 2357 in Scenario 2, and 3299 in Scenario 3. The 3-year NHS budget impact of Scenario 1 would be £45.3 million, £3.6 million (difference ‒92.0%) with Scenario 2, and £46.3 million (difference 2.2%) in Scenario 3, but for NHS plus PSS would be ‒£48.8 million, ‒£80.4 million (64.8%), and ‒£71.3 million (46.1%), respectively. Implementation of an AF risk prediction algorithm alongside standard opportunistic screening could close the AF detection gap and prevent strokes while substantially reducing NHS and PSS combined care costs.

Lenalidomide Maintenance Therapy Post-Autologous Stem Cell Transplant: A Healthcare Cost-Impact Analysis in Europe

BACKGROUNDMultiple myeloma (MM) is a relapsing haematologic cancer that remains incurable. For patients aged < 65 years or fit patients < 70 years, autologous stem cell transplant (ASCT) is the gold standard first-line treatment. Treatment guidelines recommend lenalidomide (LEN), the only approved agent, as maintenance therapy (MT) post-ASCT (NCCN Clinical Practice Guidelines. Multiple myeloma. V3.2017; Moreau P, et al . Ann Oncol . 2017 Apr 27. [Epub ahead of print]). Post-progression, in the relapsed/refractory setting, a number of newer agents and combination treatments have been approved. While all these developments benefit patients with MM, there is a potential impact on National Health Service budget. Economic information can therefore play an important role in market access decision-making for innovative medicines.OBJECTIVEThis analysis examines the cost impact of LEN as MT post-ASCT in the context of an evolving and complex treatment pathway from the perspective of the EU5 health systems (ie, France, Germany, Italy, Spain, and the United Kingdom).METHODSA cost-pathway model was developed to compare direct costs over 5 years following ASCT from the perspective of national healthcare providers in the EU5. The model follows a cohort of patients from completion of ASCT through MT or no MT and up to 2 lines of therapy following disease progression after ASCT. LEN MT was assumed to be given at a dose of 10 mg with 50% of patients on 28/28-day dosing and another 50% on 21/28-day dosing. This reflects dosing in the Myeloma XI trial and clinical prescribing in the real world. Duration of therapy was based on the CALGB study 100104 (McCarthy PL, et al. N Engl J Med. 2012;366:1770-81). Following progression in the model, patients were allocated to the following treatments based on expert clinical opinion and assuming that all newer agents were relatively accessible in the clinic: LEN/dexamethasone (Rd), bortezomib/dexamethasone (Vd), carfilzomib/Rd, carfilzomib/dexamethasone, ixazomib/Rd, daratumumab/Rd, daratumumab/Vd, or elotuzumab/Rd. Costs considered included drug acquisition costs (at list price or public prices), administration costs, and costs for management of adverse events. Two scenarios were assessed: 1) LEN MT, in which 80% of eligible patients receive LEN therapy and 2) no MT, in which only 20% of patients receive LEN therapy. Extreme scenarios corresponding to 100% and 0% of patients receiving LEN MT were also assessed.RESULTSIn the base case, direct medical costs per patient for LEN MT were €209,600 over the 5-year period compared with €276,900 for the no MT treatment strategy. In the no MT scenario, annual costs increased from €16,000 in years 1 and 2 to €81,200 in year 5. Conversely, in the LEN MT scenario, annual costs decreased from €62,600 in years 1 and 2 to €24,400-€34,400 for years 3-5. The increase in costs in years 3-5 in the no MT scenario reflected costs for further lines of treatment. The reduction in costs for years 3-5 in the LEN MT scenario reflected the benefits of LEN MT resulting in a prolonged disease-free period. LEN MT direct medical costs over a 5-year period were therefore 24% less than those for no MT (Figure 1). In the extreme scenarios, direct medical costs per patient over 5 years were €187,200 (100% LEN MT) and €299,400 (0% LEN MT).DISCUSSIONThe results of this cost-pathway analysis suggest that LEN MT reduces the overall direct medical costs over the first 5 years post-ASCT for the management of eligible patients with MM in the context of an evolving and complex treatment pathway. Furthermore, use of LEN MT spreads the cost of management of these patients more evenly across the 5 years post-ASCT, thus easing the economic burden for the healthcare system. This analysis did not consider resource savings that are also likely to be achieved with LEN MT (Ashcroft J, et al. EHA 2017. [abstract E1463]) and may thus be a conservative estimate of the likely cost savings. Real-world cost studies are warranted to investigate further the impact on costs and resource use of the uptake of LEN MT to ensure that patients are able to benefit from the improved outcomes that access to LEN MT can provide. [Display omitted] DisclosuresJackson:Chugai: Honoraria; Celgene: Honoraria; J&J: Honoraria; Amgen: Honoraria; Takeda: Honoraria. Dutton:Celgene: Consultancy. Hughes:Celgene: Consultancy. Dhanasiri:Celgene Corporation: Employment, Equity Ownership.

Litigation in Ophthalmology against the National Health Service in England

The annual clinical negligence bill against the National Health Service (NHS) in England has increased substantially from £0.3 billion ($0.4 billion) in 2004 and 2005 to £2.3 billion ($3.0 billion) in 2019 and 2020.1 Clinical negligence accounts for more than 1.5% of the annual NHS budget in England (£148.8 billion, $193.4 billion).2 The rising costs have been attributed to increases in both claim volume and costs.2

Atrial fibrillation in the UK: predicting costs of an emerging epidemic recognizing and forecasting the cost drivers of atrial fibrillation-related costs.

Atrial fibrillation (AF) is the most common sustained heart arrhythmia and a major preventable cause of stroke, heart failure, and dementia. Atrial fibrillation already accounts for a significant amount of National Health Service (NHS) funding, and over the coming years is highly likely to impose a growing cost on NHS budgets and the wider UK healthcare system. We, therefore, need greater understanding of the main cost drivers (e.g. hospitalizations) of this increasingly prevalent arrhythmia. Such data would help with NHS resource planning over the next decades. Based on prior published data, we initially calculated the cost of AF for 1995, and then again for 2000 which was calculated from a combination of contemporary and extrapolated data from that time. These data have been used as the basis for forecasting AF costs in the UK and as a share of total NHS expenditure. Atrial fibrillation direct costs were split between cost driver categories; general practitioner (GP) consultations, GP referred OPD (outpatient department) visits, prescriptions and monitoring visits, primary admissions, and post-discharge OPD visits. Forecast assumptions used: (i) NHS expenditure from 2020 onwards assumed to increase at annual rate of 3%/year; and (ii) the UK inflation rate to increase by 2% annually. Sensitivity modelling of 3%, 4%, and 6% projected annual increase in AF prevalence amongst the population was applied. The estimated direct and proportion of NHS expenditure of AF in 2020 for each of the assumed increases of 3%, 4%, and 6% would be £1435 m (0.91%), £1741 m (1.11%), and £2548 m (1.62%), respectively. For 2030, the modelling would mean that the direct costs of AF and proportion of NHS expenditure would be £2351 m (1.11%), £3141 m (1.48%), and £5562 m (2.63%), respectively. For 2040, the modelling shows that the direct costs of AF and proportion of NHS expenditure would be £3851 m (1.35%), £5668 m (1.99%), and £12 143 m (4.27%), respectively. By far the largest contributor to the total direct AF costs in 2020 was for primary admissions (nearly 60%), with a further 7% with post-discharge outpatient clinic visits. Taken together the total for these two categories in 2020 would cost the NHS between £949 and £1685 m, depending on the projected increase in annual rate of AF prevalence. The full cost of AF related hospitalizations may be underestimated, due to the other admissions associated with a secondary coding of AF, which in 2020 are forecast to cost between £2269 and £4030 m, depending on the annual population increase of AF prevalence. There will be an increasing number of patients discharged to a nursing home after a hospital admission associated with a principal AF diagnosis, with cost estimates for this in 2000 being £111 m, and predicted to rise to between £346 and £614 m by 2020. Focusing on 2020, AF is predicted to directly cost the NHS a total of a minimum of £1435 m and a maximum of £2548 m (depending on AF prevalence); hence, between 0.9% and 1.6% of NHS expenditure, mostly from primary admissions. The total direct costs of AF would increase to 1.35-4.27% of NHS expenditure, over the next two decades. If hospitalizations can be avoided or reduced, we would substantially reduce the healthcare costs of AF to the NHS.

Is an ounce of prevention worth a pound of cure? A cross-sectional study of the impact of English public health grant on mortality and morbidity

ObjectivesThe UK government is proposing to cease cutting the local authority public health grant by reallocating part of the treatment budget to preventative activity. This study examines whether this proposal...

Cosmetic Tourism: a Costly Filler Within the National Health Service Budget or a Missed Financial Opportunity? A Local Cost Analysis and Examination of the Literature.

Cosmetic tourism is a global commodity, but patients seeking treatment for complications of international cosmetic tourism appear to be on the rise. We calculate the financial burden to a single NHS trust and summarise the literature, reviewing the implications of cosmetic tourism and summarising available guidance to assist surgeons in this ethically challenging, but expanding, field. Hospital episodes for patients with complications from cosmetic tourism between January 2016 and March 2017 were retrieved using the patient management system. The coding department provided the episode costs. A literature search was conducted using Medline, EMBASE and HBE identifying 273 English abstracts. The abstracts were reviewed for relevance followed by assessment of the 48 selected full articles by all authors and 17 papers contained relevant, new information. Eleven patients underwent management for complications of cosmetic surgery, most commonly infection, with a sum of 29 inpatient episodes and total cost of £259,732. Our study illustrates the management of complications of cosmetic surgery carries a high cost. This is not an experience limited to just this trust in the UK. Internationally, healthcare systems are evolving to raise the safety profile for cosmetic tourists, some going the extra mile to accommodate healthcare tourists, reaping the financial reward. Following the examination of the literature, we query whether NHS trusts should heighten their presence as providers of private services on the international market, eliminating numerous medical-ethic concerns associated with substandard cosmetic tourism. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

The cost of diabetic foot ulcers and amputations to the National Health Service in England.

To estimate the healthcare costs of diabetic foot disease in England. Patient-level data sets at a national and local level, and evidence from clinical studies, were used to estimate the annual cost of health care for foot ulceration and amputation in people with diabetes in England in 2014-2015. The cost of health care for ulceration and amputation in diabetes in 2014-2015 is estimated at between £837 million and £962 million; 0.8% to 0.9% of the National Health Service (NHS) budget for England. More than 90% of expenditure was related to ulceration, and 60% was for care in community, outpatient and primary settings. For inpatients, multiple regression analysis suggested that ulceration was associated with a length of stay 8.04 days longer (95% confidence interval 7.65 to 8.42) than that for diabetes admissions without ulceration. Diabetic foot care accounts for a substantial proportion of healthcare expenditure in England, more than the combined cost of breast, prostate and lung cancers. Much of this expenditure arises through prolonged and severe ulceration. If the NHS were to reduce the prevalence of diabetic foot ulcers in England by one-third, the gross annual saving would be more than £250 million. Diabetic foot ulceration is a large and growing problem globally, and it is likely that there is potential to improve outcomes and reduce expenditure in many countries.

A critical review of thyroidectomy consent in the UK.

In 2015-16, the National Health Service (NHS) Litigation Authority received 10,965 claims for clinical negligence, with surgery having the highest number of claims. Currently a sum amounting to 25% of the annual NHS budget has been ring-fenced to meet extant claims. Claims made on a basis of inadequate informed consent are increasingly seen with many achieving a successful plaintiff outcome. There are presently no UK guidelines for thyroidectomy consent. A prospective study was performed to investigate current consent practice among the British Association of Endocrine and Thyroid Surgeons (BAETS) membership and patients having previously undergone thyroidectomy. For surgeons, the Bolam legal test applied where surgeons declared what risks and complications they routinely consented for during their practice. A study was also undertaken in patients who had previously undergone thyroidectomy for cancer applying the rule of Montgomery. Consent practice from 193 surgeons and data from 415 patients was analysed. In total thyroidectomy for cancer, 95% of surgeons consent for Recurrent Laryngeal Nerve (RLN) injury and temporary or permanent voice change. 70% specifically consent for External Laryngeal Nerve (ELN) injury, 50% for tracheostomy and 55% for general anaesthetic associated complications. Analysis of patient data showed they would like to be consented for far more risks than they are presently informed about in general medical practice. There was significant variation in the consenting practice in BAETS surgeons. A BAETS approved consensus guideline to standardise UK consent practice would be appropriate. This may reduce complaints, litigation claims and guide expert witnesses.

PND28 - A BUDGET IMPACT ANALYSIS OF CLADRIBINE TABLETS VERSUS ALTERNATIVE HIGH EFFICACY TREATMENTS FOR RELAPSING MULTIPLE SCLEROSIS (RMS) IN THE UNITED KINGDOM.

Cladribine Tablets (MAVENCLAD®) received its marketing authorization from the European Medicines Agency (EMA) for the treatment of persons with Highly Active Relapsing Multiple Sclerosis (HA-RMS) in 2017. Since then, in the United Kingdom (U.K.), it was assessed by the National Institute for Health and Care Excellence (NICE) and the Scottish Medicines Consortium, where it has received positive approval for use in the National Health Service (NHS). The aim of this analysis was to assess the budget impact of Cladribine Tablets against other HA-RMS Disease Modifying Treatments (DMTs), such as alemtuzumab, fingolimod, and natalizumab in a UK setting A budget impact model with a 5year time horizon, was developed with a U.K. NHS perspective. The comparators included were; alemtuzumab, fingolimod, and natalizumab. Administration and monitoring costs were obtained from the NHS reference tariffs 2016/17. The acquisition costs were sourced from the British National Formulary (BNF) published prices. Adverse Event (AE) costs were not included in this analysis. Epidemiology of multiple sclerosis (MS) was from Jick et al (2015). Market shares were based on previous NICE costing templates. A 2.5% annual uptake assumption of Cladribine Tablets was used, which was dispersed evenly amongst comparators. Over a 5-year period, this analysis estimated that 20,729 HA-RMS patients would be eligible for a DMT. Of these, if 2,149 persons were considered treated with Cladribine Tablets it would result in a net budget change of £-7,516,705. This is a saving of 1.9% to the NHS budget. In this analysis Cladribine tablets had less acquisition, monitoring, and administration costs per patient. Due to this unique posology and lower administration and monitoring requirements, Cladribine Tablets is estimated to provide budget savings to the NHS when compared with alemtuzumab, fingolimod, and natalizumab.

PUK16 - Reina (Retrospective Study on Italian ADPKD) Disease Management Cost Study

The aim of this study was to estimate the economic burden of autosomal dominant polycystic kidney disease (ADPKD) in Italy, analyzing direct costs according to progression stage of chronic kidney disease (CKD). The primary objective was the average annual cost per patient with ADPKD in Italy. The secondary objective was the average annual cost per patient suffering from ADPKD at CKD Stage I to CKD Stage V (not under dialysis), or receiving dialysis or at the post-transplant stage. This retrospective, observational study was carried out by gathering data through a pre-specified Case Report Form (CRF) in six Italian hospitals. Costs associated with ADPKD were estimated based on identified cost drivers (n of visits, n of hospitalization, treatment costs) and the analysis was performed using the Activity-Based Costing method. Inpatient and outpatient resource consumption was collected for each patient during the period 2012-2015. Direct costs were then calculated from the perspective of the Italian National Health Service (NHS). 191 patients were enrolled. The analysis estimated an average annual cost associated with ADPKD management of € 8,108. The average annual cost of patients under dialysis was € 28,279, followed by post-transplantation and CKD V patients (respectively € 22,793 and € 13,155), CKD IV (€ 7,413) and finally CKD III, CKD II, CKD I (respectively € 1,447.5, € 674.5, € 159.7). Costs increased with disease progression, except at the post-transplant stage. Outpatient specialist care (including dialysis) represented the highest impact on total costs, followed by pharmacological therapies and hospitalizations. The study underlined the relevant economic burden of ADPKD and its direct correlation with disease stage, suggesting the importance of slowing down disease progression vs ESRD, both for patient in terms of quality of life and the NHS budget

A Generic Model for Follicular Lymphoma: Predicting Cost, Life Expectancy, and Quality-Adjusted-Life-Year Using UK Population–Based Observational Data

ObjectivesTo use real-world data to develop a flexible generic decision model to predict cost, life expectancy, and quality-adjusted life-years (QALYs) for follicular lymphoma (FL) in the general patient population. MethodsAll patients newly diagnosed with FL in the UK’s population-based Haematological Malignancy Research Network (www.hmrn.org) between 2004 and 2011 were followed until 2015 (N = 740). Treatment pathways, QALYs, and costs were incorporated into a discrete event simulation to reflect patient heterogeneity, including age and disease management. Two scenario analyses, based on the latest National Institute for Health and Clinical Excellence (NICE) guidelines (rituximab induction therapy for newly diagnosed asymptomatic patients and rituximab maintenance therapy for patients between treatments), were conducted and their economic impacts were compared to current practice. ResultsIncidence-based analysis revealed expected average lifetime costs ranging from £6,165 [US$7,709] to £63,864 [US$79,862] per patient, and average life expectancy from 75 days to 17.56 years. Prevalence-based analysis estimated average annual treatment costs of £60–65 million [US$75-80 million], accounting for approximately 10% of the United Kingdom’s annual National Health Service budget for hematological cancers as a whole. Assuming that treatment effects reported in trials are applicable to all patient groups, scenario analyses for two recent NICE guidelines demonstrated potential annual cost savings for the United Kingdom that ranged with uptake frequency from £0.6 million to £11 million [US$0.75-2.75 million]. ConclusionsCosts, survival, and QALYs associated with FL vary markedly with patient characteristics and disease management. Allowing the production of more realistic outcomes across the patient population as a whole, our model addresses this heterogeneity and is a useful tool with which to evaluate new technologies/treatments to support healthcare decision makers.

A Modeling Study of the Cost-Effectiveness of a Risk-Stratified Surveillance Program for Melanoma in the United Kingdom

BackgroundPopulation-wide screening for melanoma is unlikely to be cost-effective. Nevertheless, targeted surveillance of high-risk individuals may be. ObjectivesTo estimate the cost-effectiveness of various surveillance strategies in the UK population, stratified by risk using a simple self-assessment tool scoring between 0 and 67. MethodsA decision model comparing alternative surveillance policies from the perspective of the UK National Health Service over 30 years was developed. The strategy with the highest expected net benefit for each risk score was identified, resulting in a compound risk-stratified policy describing the most cost-effective population-wide strategy. The overall expected cost and quality-adjusted life-years (QALYs), the incremental cost-effectiveness ratio, and associated uncertainty were reported. ResultsThe most cost-effective strategy is for those with a Williams score of 15 to 21 (relative risk [RR] of 0.79–1.60 vs. a mean score of 17 in the United Kingdom) to be offered a one-off full-body skin examination, and for those with a score of 22 or more (RR 1.79+) to be enrolled into a quinquennial monitoring program, rising to annual recall for those with a risk score greater than 43 (RR 20.95+). Expected incremental cost would be £164 million per annum (~0.1% of the National Health Service budget), gaining 15,947 additional QALYs and yielding an incremental cost-effectiveness ratio of £10,199/QALY gained (51.3% probability <£30,000). ConclusionsThe risk-stratified policy would be expensive to implement but cost-effective compared with typical UK thresholds (£20,000–£30,000/QALY gained), although decision uncertainty is high. Phased implementation enrolling only higher risk individuals would be substantially less expensive, but with consequent foregone health gain.

Association between the 2012 Health and Social Care Act and specialist visits and hospitalisations in England: A controlled interrupted time series analysis.

BackgroundThe 2012 Health and Social Care Act (HSCA) in England led to among the largest healthcare reforms in the history of the National Health Service (NHS). It gave control of £67 billion of the NHS budget for secondary care to general practitioner (GP) led Clinical Commissioning Groups (CCGs). An expected outcome was that patient care would shift away from expensive hospital and specialist settings, towards less expensive community-based models. However, there is little evidence for the effectiveness of this approach. In this study, we aimed to assess the association between the NHS reforms and hospital admissions and outpatient specialist visits.Methods and findingsWe conducted a controlled interrupted time series analysis to examine rates of outpatient specialist visits and inpatient hospitalisations before and after the implementation of the HSCA. We used national routine hospital administrative data (Hospital Episode Statistics) on all NHS outpatient specialist visits and inpatient hospital admissions in England between 2007 and 2015 (with a mean of 26.8 million new outpatient visits and 14.9 million inpatient admissions per year). As a control series, we used equivalent data on hospital attendances in Scotland. Primary outcomes were: total, elective, and emergency hospitalisations, and total and GP-referred specialist visits. Both countries had stable trends in all outcomes at baseline. In England, after the policy, there was a 1.1% (95% CI 0.7%–1.5%; p < 0.001) increase in total specialist visits per quarter and a 1.6% increase in GP-referred specialist visits (95% CI 1.2%–2.0%; p < 0.001) per quarter, equivalent to 12.7% (647,000 over the 5,105,000 expected) and 19.1% (507,000 over the 2,658,000 expected) more visits per quarter by the end of 2015, respectively. In Scotland, there was no change in specialist visits. Neither country experienced a change in trends in hospitalisations: change in slope for total, elective, and emergency hospitalisations were −0.2% (95% CI −0.6%–0.2%; p = 0.257), −0.2% (95% CI −0.6%–0.1%; p = 0.235), and 0.0% (95% CI −0.5%–0.4%; p = 0.866) per quarter in England. We are unable to exclude confounding due to other events occurring around the time of the policy. However, we limited the likelihood of such confounding by including relevant control series, in which no changes were seen.ConclusionsOur findings suggest that giving control of healthcare budgets to GP-led CCGs was not associated with a reduction in overall hospitalisations and was associated with an increase in specialist visits.

A Review of NICE Methods and Processes Across Health Technology Assessment Programmes: Why the Differences and What is the Impact?

Decisions made by the National Institute for Health and Care Excellence (NICE) exert an influence on the allocation of resources within 'fixed' National Health Service budgets. Yet guidance for different types of health interventions is handled via different 'programmes' within NICE, which follow different methods and processes. The objective of this research was to identify differences in the processes and methods of NICE health technology assessment programmes and to explore how these could impact on allocative efficiency within the National Health Service. Data were extracted from the NICE technology appraisal programme, medical technologies guidance, diagnostic assessment programme, highly specialised technologies programme, and clinical guidelines process and methods manuals to undertake a systematic comparison. Five qualitative interviews were carried out with NICE members of staff and committee members to explore the reasons for the differences found. The main differences identified were in the required evidence review period, or lack thereof, mandatory funding status, the provision of a reference case for economic evaluation, the requirement for and the type of economic analysis undertaken, and the decision making criteria used for appraisal. Many of the differences found can be justified on grounds of practicality and relevance to the health technologies under assessment. Nevertheless, from a strict utilitarian view, there are several potential areas of inefficiency that could lead to the misallocation of resources within the National Health Service, although some of these might be eliminated or reduced if an egalitarian view is taken. The challenge is determining where society is willing to trade health gains between different people.

PMH11 - Advanced Therapy Medicinal Products for Alzheimer's Disease Will Shrink the National Health Service Budget

PMH11 - Advanced Therapy Medicinal Products for Alzheimer's Disease Will Shrink the National Health Service Budget

A multi-phase DES modelling framework for patient-centred care

We provide a framework for simulating the entire patient journey across different phases (such as diagnosis, treatment, rehabilitation and long-term care) and different sectors (such as GP, hospital, social and community services), with the aim of providing better understanding of such processes and facilitating evaluation of alternative clinical and care strategies. A phase-type modelling approach is used to promote better modelling and management of the specific elements of a patient pathway, using performance measures such as clinical outcomes, patient quality of life, and cost. The approach is illustrated using stroke disease. Approximately 5% of the United Kingdom National Health Service budget is spent treating stroke disease each year. There is an urgent need to assess whether existing services are cost-effective or new interventions could increase efficiency. This assessment can be made using models across primary and secondary care; in particular we evaluate the cost-effectiveness of thrombolysis (clot busting therapy), using discrete event simulation. Using our model, patient quality of life and the costs of thrombolysis are compared under different regimes. In addition, our simulation framework is used to illustrate the impact of internal discharge queues, which can develop while patients are awaiting placement. Probabilistic Sensitivity Analysis of the value parameters is also carried out.