National Health Service Funding Research Articles

Eyecare practitioner perspectives and attitudes towards myopia and myopia management in the UK

ObjectiveMany children with progressive myopia are still prescribed single-vision correction. An investigation into UK eyecare practitioners’ (ECPs) perceptions of myopia management was carried out to ascertain factors which may be...

Managing Public Health Spending Growth: Public’s Views

The need to guarantee public health spending sustainability remains on the governments’ agenda, despite constant efforts to improve health sector efficiency and to contain health spending growth. In this paper, we analyse citizens’, managers’ and health professionals’ views concerning the choice of alternative National Health Service (NHS)’ financing sources and the selection of priority areas to be financed from public funds. The main novelty of this study is the auscultation and the evaluation of different stakeholders’ perspectives concerning health spending decisions, namely, health professionals, managers and the general public. An online questionnaire was used to collect data. Methods include descriptive and inferential statistics, a Pareto graph and a factorial analysis. Our results reveal the preferable additional NHS funding sources are lottery and games of chance and the increase in alcohol and tobacco taxes. The respondents defend that priorities should consider the improvement of the population’s health status, namely, considering the universality of access, equity, effectiveness and efficiency, in line with the NHS’ mission. Health professionals are also concerned about disease prevention and health promotion. This paper contributes empirical evidence to support health manager decisions, focusing on rationing decisions and alternative financing sources.

A real-world study of the first use of palbociclib for the treatment of advanced breast cancer within the UK National Health Service as part of the novel Ibrance® Patient Program.

The Ibrance® Patient Program was established to provide access to palbociclib for UK National Health Service (NHS) patients with metastatic breast cancer (MBC), pending a funding decision. Non-interventional cohort study involving a retrospective medical record review of patients commenced on palbociclib between April and December 2017 at eight UK centres. Primary outcomes included clinicopathological characteristics, treatment patterns, clinical outcomes and selected adverse events. Overall, 191 patients were identified, median age of 57.0 years (range 24.3-90.9); 30% were diagnosed with de novo MBC; 72% received first-line and 10% as ≥ second-line treatment. Median progression-free survival (95% CI) was 22.8 months (16.5-not reached [NR]) in first-line; NR in patients with de novo MBC; 7.8 months (6.8-NR) in ≥ second-line (median follow-up: 24 months). Median overall survival (OS) was NR in the overall cohort; OS rate (95% CI) at 24 months was 74.2% (67.1-81.9%) in first-line; 82.1% (72.6-92.8%) in patients with de novo MBC; 55.0% (37.0-81.8%) in ≥ second-line. Forty-seven per cent of patients developed grade 3-4 neutropenia; 3% febrile neutropenia. This study supports the effectiveness of palbociclib and demonstrates the benefit to patients of early access schemes that bridge the gap between regulatory approval and NHS funding for new medicines. Clinical trial: ClinicalTrial.gov:NCT03921866.

BH09 Patient experience of off-label Janus kinase inhibitor use for alopecia areata in a cohort of 34 patients from a single UK practitioner: exploring changing trends in healthcare provision and access to drug treatments

Abstract We present data from a UK cohort of patients with alopecia areata (AA) who have sought Janus kinase inhibitor (JAKi) treatments prior to National Health Service funding. We have explored referral methods, access to consultations, and shared care in monitoring and acquisition of medication both from the UK and abroad. We have looked at the drugs and dosage, adjuvant therapies and response to treatment, and report data on side-effects and reasons for changing drugs or stopping treatment. Thirty-four patients (25 adults and nine children) self-referred to a UK-based private hair clinic for JAKi treatment over a period of 36 months. The median age of patients was 40 years (interquartile range 18–50). The patients sought treatment from a wide geographical area in the UK, with one patient living 400 miles from the clinic. Seventeen (50%) and 14 (41%) patients were prescribed baricitinib and tofacitanib, respectively, with three (9%) patients prescribed both. Nineteen (56%) patients had severe alopecia with > 95% hair loss. Social media, in particular a closed Facebook group, was an important source of referral and information on sourcing medication from abroad. Nine per cent of consultations were virtual (telephone/video). The cost of treatment varied from £100 per month to £1400, with a large difference between UK-sourced medication and that from abroad. Eight (24%) patients showed no scalp regrowth response to first-line treatment, despite dose escalation, with one subsequently experiencing total hair regrowth on swapping to a different JAKi class. One patient had to stop treatment after developing breast cancer. JAKi are an exciting and emerging treatment for AA that are yet to be widely prescribed by UK practitioners. However, the response to JAKi is not universal. Owing to the cost of private prescription, patients are choosing to source JAKi from abroad. Our study presents data on how the alopecia community has helped inform patients about treatment access.

Real-world treatment sequencing and outcomes for patients with advanced renal cell carcinoma treated with cabozantinib after first-line checkpoint inhibitor-based combination therapy: Results from the CARINA study.

e16512 Background: Real-world data are required to guide the optimal sequencing of therapies for advanced renal cell carcinoma (aRCC) when first-line (1L) checkpoint inhibitor (CPI)-based combinations are used. CARINA is a retrospective, non-interventional study of treatment sequencing and outcomes in patients with aRCC who progressed to second-line (2L) treatment after 1L CPI-based combination therapy. Methods: Electronic prescribing records and hospital medical records from nine participating UK specialist centers were reviewed to identify patients (aged ≥ 18 years) with a diagnosis of aRCC who received 2L therapy after 1L CPI-based combination therapy in line with UK National Health Service funding policy. The primary objective was to describe the treatment pathways of patients with aRCC who received 1L CPI-based combination and subsequent therapy. Secondary objectives included descriptive analysis of: duration of treatment (DoT), objective response rate (ORR), progression-free survival (PFS) and overall survival (OS). Here we report a descriptive analysis of outcomes for subgroups who received 2L cabozantinib or other 2L therapies. Results: Between April 2015 and June 2022, data were collected from 281 patients (163 patients received 2L cabozantinib and 118 received other 2L therapies after 1L CPI-based therapy). Overall, mean (standard deviation [SD]) age at aRCC diagnosis was 59.4 (10.1) years, 76.5% were male and 87.5% had clear-cell aRCC (including those with a clear-cell component). In the 2L cabozantinib and other 2L therapies subgroups, the most common 1L regimens were ipilimumab + nivolumab (79.1% and 60.2%, respectively), axitinib + avelumab (9.8% and 22.0%) and pembrolizumab + axitinib (9.8% and 9.3%). Outcomes of 2L treatment for the 2L cabozantinib and other 2L therapies subgroups are shown in the Table. Conclusions: Among patients with aRCC who progressed to 2L treatment after 1L CPI-based therapy, the most common 1L therapies were ipilimumab + nivolumab followed by axitinib + avelumab. DoT and ORR were numerically better with 2L cabozantinib than with other 2L therapies, demonstrating the antitumor effect of 2L cabozantinib after 1L CPI-based therapy. Clinical trial information: NCT04957160 . [Table: see text]

Homologous recombination deficiency in newly diagnosed FIGO stage III/IV high-grade epithelial ovarian cancer: a multi-national observational study

ObjectiveOlaparib plus bevacizumab maintenance therapy improves survival outcomes in women with newly diagnosed, advanced, high-grade ovarian cancer with a deficiency in homologous recombination. We report data from the first year...

The Government’s NHS Funding Policy Since 2018: An Analysis of Its Evolution and Reception

Since Theresa May’s speech on the occasion of the 70th anniversary of the National Health Service (NHS) in June 2018, the issue of NHS funding has always been at the top of the Conservative government’s policy agenda. Enacted with the NHS Funding Act (2020), the NHS Long Term Plan (NHSLTP) guaranteed real term increases of over 3 per cent a year for five years to the NHS, which at first sight appeared relatively generous after eight years of austerity policies. The article shows, however, that even before the onset of the Covid-19 pandemic in March 2020, this increase was widely criticised as too low to enable the NHS to cope with the hospital waiting lists and estate maintenance backlog that had built up over time. Since 2021, the government has committed new funds to the NHS beyond the NHSLTP which will bring an increase of nearly 4 per cent a year to NHS England’s budget until 2025. Nonetheless, the article argues that the government’s NHS funding policy has lacked clarity and direction since 2019 and that the new funding promises will only be secured at the expense of the social care sector which raises questions about the long-term future of both sectors, such is their interdependence.

Research priorities for venous conditions: results of the UK Vascular James Lind Alliance Priority Setting Process

Introduction: Venous disease comprises a range of conditions of varying severity, which can result in pain and discomfort and a reduced quality of life. The annual costs for the treatment and management of venous disease in the UK is in the order of billions of pounds. It is vitally important to direct finite National Health Service (NHS) funding into areas that will maximise health outcomes and reduce the burden on the NHS. To address the issue of where best to target resources and research, the Vascular Society of Great Britain and Ireland (VSGBI) in association with the James Lind Alliance (JLA) undertook a national Priority Setting Process (PSP) for vascular conditions. This paper presents the results of this process, with a focus on the topic of ‘venous conditions’. Methods: A modified JLA Priority Setting Partnership was developed to gather clinician, patient and carer research priorities for vascular conditions. Consensus workshops were held to discuss clinician and patient priorities and agree a list of joint research priorities. Consensus was achieved using the nominal group technique and a ranked ‘top 10’ list of research priorities for venous conditions was established. Results: In the first phase (clinician-led survey), 481 clinicians submitted 1,231 research questions related to vascular conditions in general. Of these, 130 venous-specific research priorities were reduced to 13 overarching summary priorities recirculated for interim scoring. In the second phase (patient and carer-led survey), 373 patients and carers submitted 582 research priorities. Of these, 101 venous-specific priorities were reduced to 22 overarching summary priorities and recirculated for interim scoring. In the third phase (consensus workshop), clinician and patient priorities were amalgamated into 14 priorities for discussion. The final ‘top 10’ list of venous condition research priorities relate to: access to specialist venous services, prevention, wound healing, pain management, education and compliance. Conclusions: The ‘top 10’ venous-related priorities demonstrate the research areas considered to be most important from the perspective of patients, carers and healthcare professionals. Researchers can now focus their efforts on developing research questions and studies to address these priorities and funders should increase their investment to support new studies in these areas of greatest importance.

Cost-effectiveness of bariatric surgery and non-surgical weight management programmes for adults with severe obesity: a decision analysis model

ObjectivesTo determine the most cost-effective weight management programmes (WMPs) for adults, in England with severe obesity (BMI ≥ 35 kg/m2), who are more at risk of obesity related diseases.MethodsAn economic evaluation of five different WMPs: 1) low intensity (WMP1); 2) very low calorie diets (VLCD) added to WMP1; 3) moderate intensity (WMP2); 4) high intensity (Look AHEAD); and 5) Roux-en-Y gastric bypass (RYGB) surgery, all compared to a baseline scenario representing no WMP. We also compare a VLCD added to WMP1 vs. WMP1 alone. A microsimulation decision analysis model was used to extrapolate the impact of changes in BMI, obtained from a systematic review and meta-analysis of randomised controlled trials (RCTs) of WMPs and bariatric surgery, on long-term risks of obesity related disease, costs, quality adjusted life years (QALYs) and incremental cost-effectiveness ratios (ICERs) measured as incremental cost per QALY gained over a 30-year time horizon from a UK National Health Service (NHS) perspective. Sensitivity analyses explored the impact of long-term weight regain assumptions on results.ResultsRYGB was the most costly intervention but also generated the lowest incidence of obesity related disease and hence the highest QALY gains. Base case ICERs for WMP1, a VLCD added to WMP1, WMP2, Look AHEAD, and RYGB compared to no WMP were £557, £6628, £1540, £23,725 and £10,126 per QALY gained respectively. Adding a VLCD to WMP1 generated an ICER of over £121,000 per QALY compared to WMP1 alone. Sensitivity analysis found that all ICERs were sensitive to the modelled base case, five year post intervention cessation, weight regain assumption.ConclusionsRYGB surgery was the most effective and cost-effective use of scarce NHS funding resources. However, where fixed healthcare budgets or patient preferences exclude surgery as an option, a standard 12 week behavioural WMP (WMP1) was the next most cost-effective intervention.

Response to first vaccination against SARS-CoV-2 in patients with multiple myeloma

Response to first vaccination against SARS-CoV-2 in patients with multiple myeloma

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.

Measuring public preferences between health and social care funding options

Background and objectivesAdditional funding will be needed to meet the growing demand for health and social care in the UK. What is the most acceptable way to raise it? Options range from taxation to mandatory insurance, voluntary insurance and user charges. We sought to analyse the preferences of the UK general public. MethodsAn online quantitative survey embedded within a DCE was undertaken with a representative sample of 2,756 members of the public in England, Northern Ireland, Scotland and Wales, recruited from a survey panel. The DCE was designed on the basis of detailed background research including focus groups and cognitive interviews. The survey also collected information on respondents', age, health state, experience of health and social care, income, employment status and education; and tested respondents’ knowledge and awareness of National Health Service (NHS) and social care funding levels and sources. From the DCE data we developed models to understand the influence that differences in attributes had on the propensity to choose funding mechanisms. ResultsFrom the scaled MNL model results, all sections of the public – across age groups, income groups, employment status, health status and countries of the UK – would like additional funding for adult social care to be raised in the same way as additional NHS funding. Specifically, the public prefer a collective rather than individualistic approach to raising additional funds; and preferably a progressive system. All age groups prefer that contributions should not differ by age per se. Raising additional funds should for preference be by a public, not a private, organisation. There is support for earmarking the funds raised to only be used for health care or social care. Preferences are very similar across the four UK countries, once age and socioeconomic characteristics are controlled for. ConclusionsThis research provides novel evidence to help policy makers understand the relative public acceptability of different options for raising additional funds for health and adult social care in the UK. We find uniformity of preferences across the UK countries and across sub-groups of the population.

Educational Inequalities in Hospital Use Among Older Adults in England, 2004-2015.

Policy Points US policymakers considering proposals to expand public health care (such as “Medicare for all”) as a means of reducing inequalities in health care access and use could learn from the experiences of nations where well‐funded universal health care systems are already in place.In England, which has a publicly funded universal health care system, the use of core inpatient services by adults 65 years and older is equal across groups defined by education level, after controlling for health status. However, variation among these groups in the use of outpatient and emergency department care developed between 2010 and 2015, a period of relative financial austerity.Based on England's experience, introducing universal health care in the United States seems likely to reduce, but not entirely eliminate, inequalities in health care use across different population groups. ContextExpanding access to health care is once again high on the US political agenda, as is concern about those who are being “left behind.” But is universal health care that is largely free at the point of use sufficient to eliminate inequalities in health care use? To explore this question, we studied variation in the use of hospital care among education‐level‐defined groups of older adults in England, before and after controlling for differences in health status. In England, the National Health Service (NHS) provides health care free to all, but the growth rate for NHS funding has slowed markedly since 2010 during a widespread austerity program, potentially increasing inequalities in access and use.MethodsNovel linkage of data from six waves (2004‐2015) of the English Longitudinal Study of Ageing (ELSA) with participants’ hospital records (Hospital Episode Statistics [HES]) produced longitudinal data for 7,713 older adults (65 years and older) and 25,864 observations. We divided the sample into three groups by education level: low (no formal qualifications), mid (completed compulsory education), and high (at least some higher education). Four outcomes were examined: annual outpatient appointments, elective inpatient admissions, emergency inpatient admissions, and emergency department (ED) visits. We estimated regressions for the periods 2004‐2005 to 2008‐2009 and 2010‐2011 to 2014‐2015 to examine whether potential education‐related inequalities in hospital use increased after the growth rate for NHS funding slowed in 2010.FindingsFor the study period, our sample of ELSA respondents in the low‐education group made 2.44 annual outpatient visits. In comparison, after controlling for health status, we found that participants in the high‐education group made an additional 0.29 outpatient visits annually (95% confidence interval [CI], 0.11‐0.47). Additional outpatient health care use in the high‐education group was driven by follow‐up and routine appointments. This inequality widened after 2010. Between 2010 and 2015, individuals in the high‐education group made 0.48 (95% CI, 0.21‐0.74) more annual outpatient visits than those in the low‐education (16.9% [7.5% to 26.2%] of annual average 2.82 visits). In contrast, after 2010, the high‐education group made 0.04 (95% CI, −0.075 to 0.001) fewer annual ED visits than the low‐education group, which had a mean of 0.30 annual ED visits. No significant differences by education level were found for elective or emergency inpatient admissions in either period.ConclusionsAfter controlling for demographics and health status, there was no evidence of inequality in elective and emergency inpatient admissions among the education groups in our sample. However, a period of financial budget tightening for the NHS after 2010 was associated with the emergence of education gradients in other forms of hospital care, with respondents in the high‐education group using more outpatient care and less ED care than peers in the low‐education group. These estimates point to rising inequalities in the use of hospital care that, if not reversed, could exacerbate existing health inequalities in England. Although the US and UK settings differ in many ways, our results also suggest that a universal health care system would likely reduce inequality in US health care use.

Should mitochondrial replacement therapy be funded by the National Health Service?

A clinical trial on mitochondrial replacement therapy (MRT) is currently being conducted and if this technique proves effective, National Health Service (NHS) England will fund MRT through the highly specialised...

Quantifying the impact of delayed delivery of cardiac rehabilitation on patients' health.

BackgroundDespite its role as an effective intervention to improve the long-term health of patients with cardiovascular disease and existence of national guidelines on timeliness, many health services still fail to offer cardiac rehabilitation in a timely manner after referral. The impact of this failure on patient health and the additional burden on healthcare providers in an English setting is quantified in this article.MethodsTwo logistic regressions are conducted, using the British Heart Foundation National Audit of Cardiac Rehabilitation dataset, to estimate the impact of delayed cardiac rehabilitation initiation on the level of uptake and completion. The results of these regressions are applied to a decision model to estimate the long-term implications of these factors on patient health and National Health Service expenditure.ResultsWe demonstrate that the failure of 43.6% of patients in England to start cardiac rehabilitation within the recommended timeframe results in a 15.3% reduction in uptake, and 7.4% in completion. These combine to cause an average lifetime loss of 0.08 years of life expectancy per person. Scaled up to an annual cohort this implies 10,753 patients not taking up cardiac rehabilitation due to the delay, equating to a loss of 3936 years of life expectancy. We estimate that an additional £12.3 million of National Health Service funding could be invested to alleviate the current delay.ConclusionsThe current delay in many patients starting cardiac rehabilitation is causing quantifiable and avoidable harm to their long-term health; policy and research must now look at both supply and demand solutions in tackling this issue.

907-P: Striking Improvements in HbA1c following Commencement of Flash Glucose Monitoring in Type 1 Diabetes

Little evidence currently supports the efficacy of Flash Monitoring (FM) in type 1 diabetes. We present the largest prospective study of clinical outcomes following FM. National Health Service (NHS) funding for FM was introduced in Feb 2018 in our center. We evaluated outcomes in 900 people with T1DM. Baseline HbA1c was the most recent value prior to commencing FM. Control HbA1c data were obtained from 518 people with no prior or current FM use. Pre- and post-FM hypoglycemia and Hospital Anxiety and Depression Scale (HADS) data were available in 57%. Hospital admission and test-strip prescription data were obtained for the 6 months following NHS-funding and the corresponding period the previous year. Median age was 42 years (IQR 30 - 55). Mean baseline HbA1c was 65±15 mmol/mol. Pre-FM, 34.2% had HbA1c <58 mmol/mol (7.5%) which rose to 50.9% at next follow-up (median 343 days from baseline HbA1c), P < 0.001. Those with HbA1c > 75 mmol/mol (9.0%) fell from 17.8% to 8.5%, P < 0.001. Mean reduction in HbA1c was 5.6±10.9 mmol/mol (P < 0.001) but was greater in those with baseline HbA1c above 75mmol/mol (-15.4±16.8 mmol/mol, P < 0.001). In the control group, HbA1c did not change across the corresponding period (+0.2 mmol/mol, P = 0.66). In multivariate analysis, less frequent SMBG pre-FM (P = 0.03), higher HbA1c (P <0.001) and higher socioeconomic status (P = 0.02) were all associated with greater likelihood of a ≥5 mmol/mol fall in HbA1c. Impaired awareness of hypoglycemia (IAH) improved, in those with a prior history of IAH, after FM use (P < 0.001). HADS depression (2 [1 - 5] vs. 1 [0 - 3], P < 0.0001) and anxiety scores (2 [1 - 5] vs. 1 [0 - 3], P = 0.03) were higher following FM use. DKA admissions fell significantly (2 vs. 8, P = 0.02) but no effect was observed on total admissions or emergency department attendance. Blood glucose test strip prescribing fell to 14.3% of pre-FM levels (P < 0.01). FM is associated with reduced DKA admissions and marked improvement in glycemic control across a wide range of people with T1DM. Disclosure F.W. Gibb: None. R.H. Stimson: None. J.A. McKnight: Other Relationship; Self; Boehringer Ingelheim International GmbH, Lilly Diabetes, MedImmune, Novo Nordisk Inc. V. Tyndall: None. S.A. Ritchie: Other Relationship; Self; MedImmune, Novo Nordisk Inc. N.N. Zammitt: None. A.R. Dover: Other Relationship; Self; Abbott.

The lost worlds of royal commissions in the NHS: The unaccountable in pursuit of the unanswerable?

There have been recent calls for a royal commission (RC) on the British National Health Service (NHS). This article focuses on the impact of RCs and similar advisory bodies, particularly on finance recommendations, of three inquiries with broad remits across the whole of the NHS from very different periods: Guillebaud (1956); Royal Commission on the National Health Service (1979); and House of Lords Select Committee on the Long-term Sustainability of the NHS (2017). These inquiries appear to have had rather limited impacts, especially on NHS funding. First, there appears to be some hesitancy in suggesting precise figures for NHS expenditure. Second, the reports are advisory, and governments can ignore their conclusions. Third, governments have ignored their conclusions. In the 1950s and the 1980s, contrary to the recommendations of the inquiries, NHS expenditure subsequently grew only slowly, and charges were increased. In short, asking an independent RC to provide answers on NHS expenditure is perhaps the unaccountable in pursuit of the unanswerable.

A discrete event simulation model to evaluate the treatment pathways of patients with cataract in the United Kingdom

BackgroundThe number of people affected by cataract in the United Kingdom (UK) is growing rapidly due to ageing population. As the only way to treat cataract is through surgery, there is a high demand for this type of surgery and figures indicate that it is the most performed type of surgery in the UK. The National Health Service (NHS), which provides free of charge care in the UK, is under huge financial pressure due to budget austerity in the last decade. As the number of people affected by the disease is expected to grow significantly in coming years, the aim of this study is to evaluate whether the introduction of new processes and medical technologies will enable cataract services to cope with the demand within the NHS funding constraints.MethodsWe developed a Discrete Event Simulation model representing the cataract services pathways at Leicester Royal Infirmary Hospital. The model was inputted with data from national and local sources as well as from a surgery demand forecasting model developed in the study. The model was verified and validated with the participation of the cataract services clinical and management teams.ResultsFour scenarios involving increased number of surgeries per half-day surgery theatre slot were simulated. Results indicate that the total number of surgeries per year could be increased by 40% at no extra cost. However, the rate of improvement decreases for increased number of surgeries per half-day surgery theatre slot due to a higher number of cancelled surgeries. Productivity is expected to improve as the total number of doctors and nurses hours will increase by 5 and 12% respectively. However, non-human resources such as pre-surgery rooms and post-surgery recovery chairs are under-utilized across all scenarios.ConclusionsUsing new processes and medical technologies for cataract surgery is a promising way to deal with the expected higher demand especially as this could be achieved with limited impact on costs. Non-human resources capacity need to be evenly levelled across the surgery pathway to improve their utilisation. The performance of cataract services could be improved by better communication with and proactive management of patients.

Funding and policy incentives to encourage implementation of point-of-care C-reactive protein testing for lower respiratory tract infection in NHS primary care: a mixed-methods evaluation

ObjectivesUtilisation of point-of-care C-reactive protein testing for lower respiratory tract infection has been limited in UK primary care, with costs and funding suggested as important barriers. We aimed to use...

Societal Preferences for Funding Orphan Drugs in the United Kingdom: An Application of Person Trade-Off and Discrete Choice Experiment Methods

BackgroundIt is unclear whether UK National Health Service (NHS) policies for orphan drugs, which permit funding of non–cost-effective treatments, reflect societal preferences. MethodsWe conducted person trade-off (PTO) and discrete choice experiment (DCE) among 3950 adults selected to be representative of the UK general population. Experimental design was informed by surveys of patients affected by rare diseases, their caregivers, health care staff, and policymakers. Societal preferences were estimated in relation to treating a common disease, increases in waiting lists, or filling of vacant NHS posts. Results of the DCE were applied to recently licensed orphan drugs. ResultsOn the basis of equal cost, the majority of respondents to the PTO (54%; 95% confidence interval [CI] 50–59) chose to allocate funds equally between patients treated for rare diseases and those treated for common diseases, with 32% (95% CI 28–36) favoring treating rare diseases over treating common diseases (14%; 95% CI 11–17), which this reduced to 23% (95% CI 20–27) when rare disease treatments were 10 times more expensive. When framed differently, more respondents prioritized not increasing waiting list size (43%; 95% CI 39–48) than to treat rare disease patients (34%; 95% CI 30–38). DiscussionThe DCE indicated a greater preference for treating a common disease over a rare disease. Respondents agreed with five of 12 positive appraisal recommendations for orphan drugs, even if their list price was higher, but preferred the NHS not to fund the remainder. ConclusionsThe general public does not value rarity as a sufficient reason to justify special consideration for additional NHS funding of orphan drugs. This has implications regarding the appropriateness of operating higher thresholds of cost-effectiveness.