Memorandum by Abbott UK
Abbott welcomed the NAO report on Services for people with Rheumatoid Arthritis and believes that it is vital to undertake value-for-money analyses to examine the cost of ill-health to the Treasury as a whole rather than to individual government departments. The report contained a number of powerful recommendations: especially on the cost-effectiveness of earlier treatment; the creation of more Early Arthritis Clinics; and the use of multidisciplinary teams to support people remain in or return to work.
We were concerned by the NAO's findings that there continues to be a lack of integration between primary and secondary care, and agree with other organisations that the Government should appoint a National Clinical Director for musculoskeletal disorders (MSDs) to provide enhanced strategic direction and oversight. At the same time, the 2010/11 NHS Operating Framework needs to prioritise rheumatology and MSD services due to their significant impact on incapacity benefit.
1. Abbott is a global, broad-based health care company devoted to the discovery, development, manufacture and marketing of pharmaceuticals and medical products, including nutritionals, devices and diagnostics. The company employs more than 72,000 people and markets its products in more than 130 countries.
2. While Abbott's expertise lies in the health sector, we have been particularly active over the past few years in supporting research into the relationship between health and work. We have sought to address key policy questions such as how to build a more 'work-focused' NHS and ensure that patients' health needs are well supported in the workplace.
3. Abbott's particular interest is in the field of MSDs such as rheumatoid arthritis (RA) and ankylosing spondylitis (AS). MSDs are one of the most common causes of work-limiting health problems and long-standing illness, and the second biggest cause of sickness absence.[i] In 2007 Abbott supported a Work Foundation study into the effect of MSDs on labour market participation - a project which is now being rolled-out across Europe.[ii]
The NAO Report
4. Abbott welcomed the National Audit Office
report on Services for people with
Rheumatoid Arthritis. Given the current financial climate and
5. We welcomed the NAO's recommendation that treatment of RA should be started as early as possible, ideally within three months, and that initial cost increases to the NHS due to higher expenditure on drugs and associated costs would be offset by productivity gains of £31 million for the economy due to reduced sick leave and unemployment. The report noted that at present only 10 per cent of patients with RA are treated within three months of symptom onset. [iii]
6. As such, we strongly support the creation of more Early Arthritis Clinics (EAC), given that NAO modelling showed that the wider adoption of an EAC approach could result in an initial cost saving to primary care of about £3 million, with annual efficiency savings for the NHS of about £2 million. It should be noted that the NAO model did not account for the initial investment that might be needed for an EAC approach to be more widely established because its analysis of spending on RA patients by acute trusts with and without an EAC showed "no significant difference" in spending.[iv]
7. We were concerned by the NAO's findings that there continues to be a lack of integration between primary and secondary care and little incentive for changing the way services are currently configured.[v] This follows a 2009 report by the Arthritis and Musculoskeletal Alliance (ARMA) which highlighted poor implementation of the Government's 2006 Musculoskeletal Services Framework[vi], and a King's Fund report in 2009 which found that "patients and professionals perceive an unacceptably wide variation in the level and quality of care currently available".[vii]
8. Abbott endorses the recommendation that Primary Care Trusts should work with providers to ensure that all people with RA are offered a personalised care plan which should support them to remain in or return to work. We also support the recommendation that PCTs need to assess the number of people with RA in their population, and identify what specialist and multidisciplinary services they need.[viii] An example of such a multidisciplinary service can be found at the Department of Rheumatology in Bolton, which aims to break down the boundaries between primary and secondary care settings and whose staff includes consultants, advanced rheumatology practitioners, physiotherapists, an occupational therapist, and counsellors. An article outlining the Bolton case study has been included with this submission.
9. Following Dame Carol Black's review of the health of the working age population, we encourage the swift implementation of "Fit Notes" to prompt GPs to take action which will directly support a patient's return to work, such as urgent referrals to a specialist rheumatologist, physiotherapist or occupational therapist. The NAO report recommends that that the Department of Health and the Royal Colleges should cover RA in the ongoing continuing professional development of primary healthcare professionals, requiring the early referral of suspected cases and using tools such as the 18-week commissioning pathway for inflammatory arthritis.[ix] The Government should now ensure that the pathway is implemented as quickly as possible so that all RA patients can be treated within three months.
10. Whilst we agree with the NAO's recommendation that there should be clearer links between NHS and Jobcentre Plus services, we believe that employment services should be a "one-stop shop", which include routine liaison with healthcare professionals, fast-track referral to occupational therapy services and employer "check-lists" to ensure employers are prepared to make reasonable adjustments where appropriate.
11. The NAO report found that 86 per cent of acute trusts are able to prescribe biologic medicines to all patients in accordance with National Institute for Health and Clinical Excellence (NICE) technology appraisal guidance. However, whilst the Department of Health's 2006 Musculoskeletal Services Framework acknowledges that year-on-year costs of prescribing "TNF alpha inhibitors" are likely to be offset by keeping patients with RA at work[x], NICE is not yet tasked with considering the wider impact of its guidance on employment - a recommendation of the Health Select Committee in 2007.[xi] In July of this year, a review by Professor Sir Ian Kennedy into this issue also called for more research to be carried out into how NICE might incorporate societal and employment costs into its appraisals.[xii]
12. The Department of Work and Pensions has committed itself to reducing the flow of people out of work due to ill-health[xiii], however the current NHS Operating Framework is noticeable for the lack of priority given to tackling MSDs.[xiv] The 2010/11 NHS Operating Framework needs to prioritise rheumatology and MSD services due to their significant impact on incapacity benefit - one of the key drivers of public spending. The new NHS Indicators for Quality Improvement should also include greater emphasis on the treatment of MSDs - especially on facilitating earlier intervention in order to increase productivity, in line with the findings of the NAO report.
13. The Government should appoint a "clinical champion", or National Clinical Director for MSDs to provide enhanced strategic direction and oversight - a call endorsed by a recent House of Commons EDM.[xv] This would follow a recent move to appoint a National Clinical Director to lead the development of a National Strategy for Liver Disease, as announced by the Department of Health in October 2009.[xvi] A similar National Clinical Director for MSDs could coordinate the pilot of "Into-work" sessions across the country, with the aim of bringing together local NHS workforce development leads, commissioners and heath professionals to discuss service re-design to more effectively and efficiently help people with MSDs such as RA remain in or return to work.
14. In order to help realise the potential savings to the Treasury as highlighted in the NAO report, the Department of Health should introduce new measures that include work as a clinical outcome for patients and which are considered when evaluating a PCT's performance. This could be supported by appropriate materials such as a Department of Health care pathway and the anticipated NICE commissioning toolkit on RA, due later this year.
[i] Health and Safety Executive, Health and Safety Statistics 2007/2008, p. 6, p. 23- http://www.hse.gov.uk/statistics/overall/hssh0708.pdf
[ii] The Work Foundation, Fit for Work Europe - http://www.fitforworkeurope.eu/
[iii] National Audit Office, Services for people with rheumatoid arthritis, 2009, p. 5 - http://www.nao.org.uk/idoc.ashx?docId=3884f599-9c81-4976-aa4b-4ebebbf2dba3&version=-1
[iv] National Audit Office, Services for people with rheumatoid arthritis: Economic models of identification and treatment of early rheumatoid arthritis, 2009, p. 16-17 - http://www.nao.org.uk/idoc.ashx?docId=a5368598-d965-40f8-9ce6-0f9cfdc7b046&version=-1
[v] National Audit Office, Services for people with rheumatoid arthritis, 2009, p. 10
[vi] Arthritis and Musculoskeletal Alliance, Joint working? An audit of the implementation of the Department of Health's musculoskeletal services framework, 2009, p. 3 - http://www.arma.uk.net/pdfs/MSF%20Review_FINAL1.pdf
[vii] King's Fund, Perceptions of patients and professionals on rheumatoid arthritis care, 2009, p. 24 - http://www.rheumatoid.org.uk/download.php?asset_id=615
[viii] National Audit Office, Services for people with rheumatoid arthritis, July 2009, p. 10
[ix] National Audit Office, Services for people with rheumatoid arthritis, 2009, p. 9
[x] Department of Health, The Musculoskeletal Services Framework, 2006, p. 36 - http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4138412.pdf
[xi] House of Commons Health Committee, National Institute for Health and Clinical Excellence, First Report of Session 2007-2008, volume 1, 2007, p. 6 - http://www.publications.parliament.uk/pa/cm200708/cmselect/cmhealth/27/27.pdf
[xii] Kennedy I, Appraising the Value of Innovation and Other Benefits. A Short Study for NICE, 2009, p. 6 - http://www.nice.org.uk/media/98F/5C/KennedyStudyFinalReport.pdf
[xiii] Department for Work and Pensions, DWP: Three Year Business Plan 2009-2012, 2009, p. 24 - http://www.dwp.gov.uk/docs/three-year-plan-2009.pdf
[xiv] Department of Health, The NHS in England: The operating framework for 2009/10, 2008 - http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_091446.pdf
[xv] House of Commons, Early Day Motion 1930, tabled on 20 July 2009 - http://edmi.parliament.uk/EDMi/EDMDetails.aspx?EDMID=39156&SESSION=899
[xvi] Department of Health - http://www.dh.gov.uk/en/News/Recentstories/DH_107304