National Health Service Spending Research Articles

Maggot therapy for resistant infections: the disconnect between scientific evidence, clinical acceptance and practice.

Practitioners and scientists are re-examining marginalised wound care therapies to find strategies that combat the growing problem of antimicrobial resistance (AMR) without compromising patient outcomes. Maggot therapy (MT) makes up just an estimated 0.02% of UK's National Health Service spending on wound care. This study aims to uncover why MT is not used more often, despite its affordability and high level of efficacy for both debridement and disinfection, particularly in the context of AMR infections, and to determine what can be done to ensure MT is more effectively used in the future to improve patient outcomes and manage the growing problem of AMR. For this investigation, a qualitative review of case studies using MT against AMR infections and a quantitative analysis of randomised control trials (RCTs) were performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework. Analysis showed that MT is highly effective against a range of infections and wound types, and compares well against conventional therapies. The low use of MT may be due in part to the documented 'yuck factor', often associated with maggots as well as misconceptions around the cost, efficacy and accessibility of MT. To overcome these factors, more RCTs on the spectrum and efficacy of MT across various clinical manifestations are needed, as well as professional and public engagement campaigns. MT is an underused therapy, particularly regarding AMR infections, and expanding its use in these circumstances appears warranted. MT could play a vital role in conserving the efficacy of the existing pool of antimicrobials available and should be considered in the development of antimicrobial stewardship programmes. This work was supported by the Swansea Employability Academy, Swansea University (internal funding). The authors have no conflicts of interest to declare.

Budget Impact of RefluxStop™ as a Treatment for Patients with Refractory Gastro-oesophageal Reflux Disease in the United Kingdom.

Background: Gastro-oesophageal reflux disease (GORD) is a common condition associated with heartburn and regurgitation. Standard of care for GORD patients in the UK involves initial treatment with proton pump inhibitors (PPIs) and laparoscopic antireflux surgery in patients unwilling to continue or intolerant of long-term PPI treatment. Recently, RefluxStop™, a novel, implantable medical device, has proven to be an efficacious and cost-effective treatment for patients with GORD. The current analysis aimed to describe the budget impact of introducing RefluxStop™ within National Health Service (NHS) England and Wales. Objectives: To estimate the more immediate, short-term clinical and economic effects of introducing RefluxStop™ as a therapeutic option for patients with GORD treated within NHS England and Wales. Methods: A model adherent to international best practice guidelines was developed to estimate the budget impact of introducing RefluxStop™ over a 5-year time horizon, from an NHS perspective. Two hypothetical scenarios were considered, one without RefluxStop™ (comprising PPI treatment, laparoscopic Nissen fundoplication, and magnetic sphincter augmentation using the LINX® system) and one with RefluxStop™ (adding RefluxStop™ to the aforementioned treatment options). Clinical benefits and costs associated with each intervention were included in the analysis. Results: Over 5 years, introducing RefluxStop™ allowed the avoidance of 347 surgical failures, 39 reoperations, and 239 endoscopic esophageal dilations. The financial impact of introducing RefluxStop™ was £3 029 702 in year 5, corresponding to a 1.68% increase in annual NHS spending on GORD treatment in England and Wales. Discussion: While the time horizon was too short to capture some of the adverse events of PPIs and complications of GORD, such as the development of Barrett's esophagus or esophageal cancer, the use of RefluxStop™ was associated with a substantial reduction in surgical complications, including surgical failures, reoperations, and endoscopic esophageal dilations. This favorable clinical profile resulted in cost offsets for the NHS and contributed to the marginal budget impact of RefluxStop™ estimated in the current analysis. Conclusions: Introducing RefluxStop™ as a treatment option for patients with GORD in England and Wales may be associated with clinical benefits at the expense of a marginal budget impact on the NHS.

Budget Impact of RefluxStopTM as a Treatment for Patients with Refractory Gastro-oesophageal Reflux Disease in the United Kingdom

Background: Gastro-oesophageal reflux disease (GORD) is a common condition associated with heartburn and regurgitation. Standard of care for GORD patients in the UK involves initial treatment with proton pump inhibitors (PPIs) and laparoscopic antireflux surgery in patients unwilling to continue or intolerant of long-term PPI treatment. Recently, RefluxStop™, a novel, implantable medical device, has proven to be an efficacious and cost-effective treatment for patients with GORD. The current analysis aimed to describe the budget impact of introducing RefluxStop™ within National Health Service (NHS) England and Wales. Objectives: To estimate the more immediate, short-term clinical and economic effects of introducing RefluxStop™ as a therapeutic option for patients with GORD treated within NHS England and Wales. Methods: A model adherent to international best practice guidelines was developed to estimate the budget impact of introducing RefluxStop™ over a 5-year time horizon, from an NHS perspective. Two hypothetical scenarios were considered, one without RefluxStop™ (comprising PPI treatment, laparoscopic Nissen fundoplication, and magnetic sphincter augmentation using the LINX® system) and one with RefluxStop™ (adding RefluxStop™ to the aforementioned treatment options). Clinical benefits and costs associated with each intervention were included in the analysis. Results: Over 5 years, introducing RefluxStop™ allowed the avoidance of 347 surgical failures, 39 reoperations, and 239 endoscopic esophageal dilations. The financial impact of introducing RefluxStop™ was £3 029 702 in year 5, corresponding to a 1.68% increase in annual NHS spending on GORD treatment in England and Wales. Discussion: While the time horizon was too short to capture some of the adverse events of PPIs and complications of GORD, such as the development of Barrett’s esophagus or esophageal cancer, the use of RefluxStop™ was associated with a substantial reduction in surgical complications, including surgical failures, reoperations, and endoscopic esophageal dilations. This favorable clinical profile resulted in cost offsets for the NHS and contributed to the marginal budget impact of RefluxStop™ estimated in the current analysis. Conclusions: Introducing RefluxStop™ as a treatment option for patients with GORD in England and Wales may be associated with clinical benefits at the expense of a marginal budget impact on the NHS.

Implementing an Online Program to Change Benzodiazepine Prescription: Protocol of a Hybrid Type 1 Cluster-Randomised Trial

Introduction: Excessive benzodiazepine (BZD) prescription has long been considered a serious mental health concern in many countries. Many interventions using different methodologies have been implemented to change BZD prescription patterns in primary health care settings, with limited positive results. Objectives: The primary objective of our study was to analyse the effectiveness and implementation process of an intervention aimed at changing BZD prescription patterns in a primary health care setting in Portugal. Methodology: We chose as methodology an effectiveness-implementation hybrid type 1 intervention. Our intervention was based on the development of an online platform, named ePrimaPrescribe, which was delivered using a Digital Behaviour Change Intervention (DBCI), using a two-arm cluster-randomised clinical trial. Results: We primarily aimed to evaluate the effectiveness of our DBCI in changing BZD prescription patterns using the frequency of BZD prescriptions issued per month as an outcome measure. Secondarily, we aimed to analyse the effect of ePrimaPrescribe on antidepressant prescriptions, to study the effect of the platform on diagnosis registration associated with BZDs and antidepressant prescription, and to perform a cost analysis considering the monthly National Health Service spending on BZD co-payments. Finally, we aimed to analyse the implementation process using quantitative and qualitative methods. Conclusion: With this study, we expect to contribute with a cost-effective intervention to change the complex matter of excessive BZD prescriptions, and also to improve insight into the challenges to intervention implementation processes in primary health care settings. We believe that our findings are relevant not only to the specific setting where the study was implemented, but also to all countries where primary health care plays a central role in care provision.

The Effect of 24/7, Digital-First, NHS Primary Care on Acute Hospital Spending: Retrospective Observational Analysis.

BackgroundDigital health has the potential to revolutionize health care by improving accessibility, patient experience, outcomes, productivity, safety, and cost efficiency. In England, the NHS (National Health Service) Long Term Plan promised the right to access digital-first primary care by March 31, 2024. However, there are few global, fully digital-first providers and limited research into their effects on cost from a health system perspective.ObjectiveThe aim of this study was to evaluate the impact of highly accessible, digital-first primary care on acute hospital spending.MethodsA retrospective, observational analysis compared acute hospital spending on patients registered to a 24/7, digital-first model of NHS primary care with that on patients registered to all other practices in North West London Collaboration of Clinical Commissioning Groups. Acute hospital spending data per practice were obtained under a freedom of information request. Three versions of NHS techniques designed to fairly allocate funding according to need were used to standardize or “weight” the practice populations; hence, there are 3 results for each year. The weighting adjusted the populations for characteristics that impact health care spending, such as age, sex, and deprivation. The total spending was divided by the number of standardized or weighted patients to give the spending per weighted patient, which was used to compare the 2 groups in the NHS financial years (FY) 2018-2019 (FY18/19) and 2019-2020 (FY19/20). FY18/19 costs were adjusted for inflation, so they were comparable with the values of FY19/20.ResultsThe NHS spending on acute hospital care for 2.43 million and 2.54 million people (FY18/19 and FY19/20) across 358 practices and 49 primary care networks was £1.6 billion and £1.65 billion (a currency exchange rate of £1=US $1.38 is applicable), respectively. The spending on acute care per weighted patient for Babylon GP at Hand members was 12%, 31%, and 54% (£93, P=.047; £223, P<.001; and £389, P<.001) lower than the regional average in FY18/19 for the 3 weighting methodologies used. In FY19/20, it was 15%, 35%, and 51% (£114, P=.006; £246, P<.001; and £362, P<.001) lower. This amounted to lower costs for the Babylon GP at Hand population of £1.37, £4.40 million, and £11.6 million, respectively, in FY18/19; and £3.26 million, £9.54 million, and £18.8 million, respectively, in FY19/20.ConclusionsPatients with access to 24/7, digital-first primary care incurred significantly lower acute hospital costs.

Managing NHS money in Portugal: who decides?

PurposeThe need to reduce health expenditures raises the discussion on rationing possibilities and there is a growing interest in considering society's perspectives. The aim of this paper was to evaluate Portuguese citizens' opinion regarding the imposition of limits on National Health Service (NHS) spending. We also asked who decides how NHS money is spent, in order to obtain the respondents' views on public involvement.Design/methodology/approachAn online questionnaire was used to collect data. Descriptive and inferential statistics, factorial analysis and a logit model were applied.FindingsOur results showed that most of the respondents believe citizens have low participation on NHS' financial decisions, confirming the lack of public involvement. Health professionals are more likely to agree with limits on NHS spending, which could indicate potential inefficiencies.Practical implicationsFrom a health policy perspective, we have concluded that different stakeholders should be involved before deciding how public spending limits should be implemented. Health professionals' perspectives should be considered, taking advantage of their experience.Originality/valueThe main novelty of this paper is the evaluation of whether there should be limits on NHS spending, comparing health professionals and non-health professionals.

Cured Today, Ill Tomorrow: A Method for Including Future Unrelated Medical Costs in Economic Evaluation in England and Wales.

In many countries, future unrelated medical costs occurring during life-years gained are excluded from economic evaluation, and benefits of unrelated medical care are implicitly included, leading to life-extending interventions being disproportionately favored over quality of life-improving interventions. This article provides a standardized framework for the inclusion of future unrelated medical costs and demonstrates how this framework can be applied in England and Wales. Data sources are combined to construct estimates of per-capita National Health Service spending by age, sex, and time to death, and a framework is developed for adjusting these estimates for costs of related diseases. Using survival curves from 3 empirical examples illustrates how our estimates for unrelated National Health Service spending can be used to include unrelated medical costs in cost-effectiveness analysis and the impact depending on age, life-years gained, and baseline costs of the target group. Our results show that including future unrelated medical costs is feasible and standardizable. Empirical examples show that this inclusion leads to an increase in the ICER of between 7% and 13%. This article contributes to the methodology debate over unrelated costs and how to systematically include them in economic evaluation. Results show that it is both important and possible to include future unrelated medical costs.

Methods for the economic evaluation of changes to the organisation and delivery of health services: principal challenges and recommendations.

There is a requirement for economic evaluation of health technologies seeking public funding across Europe. Changes to the organisation and delivery of health services, including changes to health policy, are not covered by such appraisals. These changes also have consequences for National Health Service (NHS) funds, yet undergo no mandatory cost-effectiveness assessment. The focus on health technologies may have occurred because larger-scale service changes pose more complex challenges to evaluators. This paper discusses the principal challenges faced when performing economic evaluations of changes to the organisation and delivery of health services and provides recommendations for overcoming them. The five principal challenges identified are as follows: undertaking ex-ante evaluation; evaluating impacts in terms of quality-adjusted life years; assessing costs and opportunity costs; accounting for spillover effects; and generalisability. Of these challenges, methods for estimating the impact on costs and quality-adjusted life years are those most in need of development. Methods are available for ex-ante evaluation, assessing opportunity costs and examining generalisability. However, these are rarely applied in practice. The general principles of assessing the cost-effectiveness of interventions should be applied to all NHS spending, not just that involving health technologies. Advancements in this area have the potential to improve the allocation of scarce NHS resources.

Projecting Expenditure on Medicines in the UK NHS

Expenditure on medicines is a readily identifiable element of health service costs. It is the focus of much attention by payers, not least in the UK even though the cost of medicines represents less than 10% of total UK National Health Service (NHS) expenditure. Projecting future medicines spending enables the likely cost pressure to be allowed for in planning the scale and allocation of NHS resources. Simple extrapolations of past trends in expenditure fail to account for changes in the rate and mix of new medicines becoming available and in the scope for windfall savings when some medicines lose their patent protection. The objective of this study is to develop and test an improved method to project NHS pharmaceutical expenditure in the UK for the period 2012-2015. We have adopted a product-by-product, bottom-up approach, which means that our projections are built up from individual products to the total market. Our projections of the impact of generic and biosimilars entry on prices and quantities of medicines sold, and of the rate of uptake of newly launched medicines, have been obtained from regression analysis of UK data. To address uncertainty, we have created a baseline and two other illustrative scenarios. We have compared our projections with actual expenditure for 2012. Our projections estimate that, between 2011 and 2015, with no change in policy or price regulation, the UK total medicines bill would increase at an average compound annual growth rate (CAGR) of between 3.1 and 4.1%. Total NHS spending on branded medicines and total NHS spending on generics are projected to increase at average CAGRs of 0.5-1.8 and 10.0-11.0%, respectively, over the same time period. For the total market, the actual growth rate for 2012 lay within our projected range. Our methodology provides a useful framework for projecting UK NHS medicines expenditure over the medium term and captures the impacts of existing medicines losing exclusivity and of new medicines being launched onto the market.

Prescribing in Parkinson's disease: a story of hope and adverse events

A review of National Health Service spending in England on prescription drugs used in Parkinsonism over the last 10 years shows that spending has risen rapidly and that newly introduced...

Estimating the financial cost of chronic kidney disease to the NHS in England

BackgroundChronic kidney disease (CKD) is a major challenge for health care systems around the world, and the prevalence rates appear to be increasing. We estimate the costs of CKD in a universal health care system.MethodsEconomic modelling was used to estimate the annual cost of Stages 3–5 CKD to the National Health Service (NHS) in England, including CKD-related prescribing and care, renal replacement therapy (RRT), and excess strokes, myocardial infarctions (MIs) and Methicillin-Resistant Staphylococcus Aureus (MRSA) infections in people with CKD.ResultsThe cost of CKD to the English NHS in 2009–10 is estimated at £1.44 to £1.45 billion, which is ∼1.3% of all NHS spending in that year. More than half this sum was spent on RRT, which was provided for 2% of the CKD population. The economic model estimates that ∼7000 excess strokes and 12 000 excess MIs occurred in the CKD population in 2009–10, relative to an age- and gender-matched population without CKD. The cost of excess strokes and MIs is estimated at £174–£178 million.ConclusionsThe financial impact of CKD is large, with particularly high costs relating to RRT and cardiovascular complications. It is hoped that these detailed cost estimates will be useful in analysing the cost-effectiveness of treatments for CKD.

The four hour target to reduce emergency department ‘waiting time’: A systematic review of clinical outcomes

Governments in Australasia are introducing emergency department length of stay (EDLOS) time targets similar to the UK 'four hour rule'. There is debate about whether this rule had beneficial effects on health-care outcomes. We sought to determine what effects the four hour time target for EDLOS had on clinically relevant outcomes in the UK by conducting a systematic search for evidence. Articles were screened by both authors independently and assessed for quality using standard tools. Differences in outcomes measured and how they were measured precluded meta-analysis. There were inconsistencies between target achievement reported by Trusts and that reported in the studies, and empirical evidence that the target might be unattainable. National Health Service spending on ED increased £820,000,000.00 (1998-2007) and emergency admissions rose overall by 35% (2002-2006), but not in all hospitals. Time to see a treating clinician and hospital mortality was unchanged. One hospital demonstrated a small reduction in return rate. The impact of the introduction of an ED time target and the associated massive financial investment has not resulted in a consistent improvement in care with markedly varying effects being reported between hospitals. Countries seeking to emulate the UK experience should proceed with caution.

The UK National Health Service approach to the economic crisis

The UK National Health Service approach to the economic crisis

Rolling The Rock Up The Mountain

Rolling The Rock Up The Mountain

Localized therapeutic hypothermia in the brain for the treatment of ischemic stroke

stroke is, according to the World Health Organization ([10][1]), the third most common cause of death in the developed countries, exceeded only by coronary heart disease and cancer. Annually, 15 million people worldwide suffer a stroke. Of these 15 million people, 5.5 million die and 5 million are

Can Americans Say No? A British Perspective

It is evident that particularly for the rich, dying is an un-American activity! This accounts in part for Americans’ spending twice as much per capita on health care as the British do. The British reluctantly accept two facts of life. First, they are all suffering from a terminal, sexually transmitted disease called life. Second, with death inevitable and resources finite, health care rationing is inevitable. Rationing involves depriving patients of care from which they could benefit and which they wish to consume. The British are much more vigorous than Americans are in “drawing the line,” as Henry Aaron, William Schwartz, and Melissa Cox show in Can We Say No? But even with Americans’ higher levels of health spending, rationing in the United States is also inevitable. Victor Fuchs articulated the explicit and implicit criteria that determine who will die and who will live, and in what degree of pain and discomfort, three decades ago.1 Because of affluence and political chicanery common to all governments assaulted by the inevitability of rationing, Americans (despite the Oregon experiment and other policies) have lost their focus on rationing, but this new book might destroy these illusions. Can We Say No? is a follow-up study of Aaron and Schwartz’s 1984 book, The Painful Prescription.2 Both books analyze the workings of the United Kingdom’s National Health Service (NHS) as seen through American eyes. Then and now the authors show that the British spend less on health care and consequently provide less care for their citizens. They also show that in the twenty-first century, the NHS is changing rapidly, largely because of the Blair government’s massive increases in public investment since 2000. Despite this growth in funding, the relative gaps in provision remain large and have increased since the 1984 book. So while the funding of care for patients with chronic renal failure in the NHS has given elderly patients increased access to dialysis, provision in this and other specialist areas remains inferior to that in the United States. The authors examine relative provision in a number of other areas—including hemophilia, stem cell transplantation, hip replacement, cardiac revascularization, and intensive care— which affect the relative quality and length of life of patients in the two countries. In all of these areas, although the United Kingdom is providing absolutely more care than in 1984, the gap between British frugality and American generosity is widening. An interesting issue explored by the authors is how, given an evidence base of clinical effectiveness, U.K. clinicians accept and explain their frugality. The authors report that NHS physicians believe that they are always doing what is appropriate for patients even though their treatment choices might result in shorter, lower-quality lives than achieved for similar patients in the United States. Of particular interest to U.S. readers is the issue of waiting times. One method of rationing health care in the NHS is to treat emergencies promptly if relatively frugally and to ration resources for elective care by making patients wait. The political pressures created by waiting lists and waiting times is one of the primary causes of the Blair reforms, which will double NHS spending in a decade and drive the share of gross domestic product (GDP) spent on the NHS to the European average of 8–9 percent. However, increases in funding take time to translate into service provision, B o o k R e v i e w s

The cost of clinically significant urinary storage symptoms for community dwelling adults in the UK.

To estimate the cost of clinically significant urinary storage symptoms (CSUSS), including costs borne by the National Health Service (NHS) and individuals, in terms of the use of goods and services in community-dwelling adults. The subjects were community-dwelling adults aged >/= 40 years and living in Leicestershire. The prevalence of CSUSS was estimated using a postal questionnaire with a randomly selected sample of 23 182 respondents. The costs associated with CSUSS were estimated using home interviews with 613 cases with and 523 subjects without CSUSS. Cases were defined on the basis of urinary symptoms of leakage, urgency, frequency and nocturia. Willingness-to-pay was used to measure intangible costs as an indicator of the value of alleviating symptoms. The estimated total annual cost to the NHS for treating CSUSS cases in community-dwelling adults was pound 536 million at 1999/2000 prices ( pound 303 million and pound 233 million for men and women, respectively). The total value of costs borne by individuals was estimated to be pound 207 million ( pound 29 million and pound 178 million for men and women, respectively). This gives total annual costs related to the use of services of pound 743 million. There were large intangible costs borne by individuals estimated to be pound 669 million ( pound 301 and pound 368 million for men and women) for the UK in terms of willingness-to-pay. The costs of CSUSS in the community amounted to approximately 1.1% of overall NHS spending for 1999/2000. Personally borne and intangible costs are also large and important components of the costs of CSUSS. There are large gender differences in the proportion of costs borne by the NHS, i.e. 91% of male and 57% of female costs.

Risk Management and Litigation in Obstetrics and Gynaecology

Money paid out for clinical negligence now accounts for a sizeable part of National Health Service spending. The trend to litigation is increasing and the specialty of obstetrics and gynaecology suffers particularly because of high awards for brain damage in babies. Numerous books and courses offer advice on how to avoid such litigation, under the titles risk management and clinical governance. However, some clinicians feel that risk management is a drain on time and resources, without much benefit to the patient. This view, I believe, is partly due to a mistaken idea that risk management is synonymous with defensive medicine. Defensive medicine is a sloppy mode of practice whereby patients are overinvestigated so that the clinician escapes criticism if the outcome is unsatisfactory. (Most investigations yield some false-positives which then lead to further tests, which may be hazardous to the patient.) Risk management, by contrast, is about identifying the risks, deciding on practical strategies to minimize them and also deciding whether they are worth taking. Individuals and departments reach differing conclusions, hence the variations in management policies nationwide.

Healthcare financing for the under-served: UK.

The National Health Service (NHS), established in 1948, is mainly funded from taxation and largely free at the point of use. Anyone resident in the UK is entitled to use it. The overall level of NHS spending is determined by the Government; and for most of its history, tight control has been exercised, resulting in spending that is lower relative to gross domestic product (GDP) than in most OECD countries. For many years NHS spending was within the range 5.5-6.2% of GDP. In March 1999 the Government committed itself to increase spending over the following five years to the average for the European Union. It is too early to assess what impact this will have on availability of healthcare, but the commitment has been accompanied by ambitious targets to reduce waiting times for treatment, to improve the responsiveness of services and to enhance the patient experience. Most NHS spending has for the past thirty or so years been distributed by population-based allocations, adjusted for factors considered to affect the need for and costs of healthcare. The allocations are spent locally on the provision of services. Additional funding streams have been used either because Government has wanted to put its weight behind the development of a specific service (hospice funding at one stage fell into this category) or because the geographical distribution of a health problem was too skewed for any formula (AIDS treatment and care fell consistently into this category). Responsibility for spending both general and specific allocations has rested with local health authorities, which may loosely be seen as geographically specific health maintenance organizations. In the current year the UK Government plans to spend some £44 billion (£1≏US$ 1.4) on health and healthcare on the 50 million population of England alone. About 1% of that total will be spent within an average-sized health authority. There are three other important sources of funding. First, about 10 million people in the UK are covered by private insurance, either employer-based or privately purchased, most of them of working age together with their families. Collectively this equates to about 1% of GDP. It mainly purchases elective treatment. Secondly, older people requiring both clinical and social care support, whether in their own home or in a residential or nursing-home setting, may be required to meet the social care part of the costs from their own resources. Thirdly, some aspects of healthcare have been relatively successful in attracting capital, revenue or (unpaid) volunteer help. Palliative care and AIDS/HIV treatment come into this category.

Cost effectiveness of ramipril treatment for cardiovascular risk reduction

OBJECTIVETo assess the cost effectiveness of ramipril treatment in patients at low, medium, and high risk of cardiovascular death.DESIGNPopulation based cost effectiveness analysis from the perspective of the health care provider in the UK. Effectiveness was modelled using data from the HOPE (heart outcome prevention evaluation) trial. The life table method was used to predict mortality in a medium risk cohort, as in the HOPE trial (2.44% annual mortality), and in low and high risk groups (1% and 4.5% annual mortality, respectively).SETTINGUK population using 1998 government actuary department data.MAIN OUTCOME MEASURECost per life year gained at five years and lifetime treatment with ramipril.RESULTSCost effectiveness was £36 600, £13 600, and £4000 per life year gained at five years and £5300, £1900, and £100 per life year gained at 20 years (lifetime treatment) in low, medium, and high risk groups, respectively. Cost effectiveness at 20 years remained well below that of haemodialysis (£25 000 per life year gained) over a range of potential drug costs and savings. Treatment of the HOPE population would cost the UK National Health Service (NHS) an additional £360 million but would prevent 12 000 deaths per annum.CONCLUSIONSRamipril is cost effective treatment for cardiovascular risk reduction in patients at medium, high, and low pretreatment risk, with a cost effectiveness comparable with the use of statins. Implementation of ramipril treatment in a medium risk population would result in a major reduction in cardiovascular deaths but would increase annual NHS spending by £360 million.