England’s Payer Stakeholders

Once NICE determines a new drug to be cost effective, local-level stakeholders in clinical commissioning groups (CCGs) and hospital trusts implement NICE’s guidance. CCGs, led by general practitioners, organise the delivery of approximately £65bn of England’s NHS budget. Specialised commissioning (approximately £20bn of the NHS budget) is delivered nationally instead of regionally through NHS England. NHS England, run by the UK Department of Health, is legally in charge of the UK-wide NHS budget and decision making. The NHS in England spends approximately £10bn on essential drugs (across all commissioning).

Working with NICE

While NICE does not have a formal role in price setting, the panel gives the critical stamp of approval leading to National Health System use and reimbursement. NICE is the main health technology assessment (HTA) body in England, determining clinical and cost effectiveness of pharmaceutical and biopharmaceutical products. NICE uses quality-adjusted life years (QALYs) to measure burden of illness in terms of shortfall of life and length, and is derived via an incremental cost-effectiveness ratio, or ICER.

The need to prove cost effectiveness to NICE before a drug can be recommended for use by the National Health Service encourages companies to negotiate the price paid to satisfy NICE’s criteria. This has also prompted companies to offer deals that have an impact on pricing.

Important Points to Keep in Mind

Medicines that have been approved but have not yet received NICE guidance see little-to-no uptake, known as “NICE blight.” NHS organisations can technically start using the drug but many wait for NICE guidance, which can take between six months to, in some cases, two years.

For the majority of new medicines, the decisions on use are made at a local level by drugs and therapeutic committees, which include healthcare providers as well as commissioners. Medicines are then further assessed within local health economies before being approved for CCG and hospital drug formularies. With more than 200 CCGs, this model means medicine uptake can be inequitable and slower than anticipated.

New medicines where decision on use is made at the national level, through specialised commissioning, also have their own problems. In many cases, this national process is seen as a ‘you only get one chance at approval’ route.

Implications for Industry

Demonstrating the value of a new drug relative to standard of care, which can differ between countries and global regions, and creating effective market access and communications strategies are critical to realising maximum commercial value in England. The Pharmaceutical Price Regulation Scheme (PPRS) plays an important role in shaping the relationship between industry, the NHS and the English healthcare landscape. Knowing the ins and outs of this policy and how it plays out at a local, regional, national and UK-wide level is essential. Finally, identifying and communicating to all relevant key market stakeholders is equally important.

NICE’s Ongoing Assessment

During NICE’s HTA appraisal process, manufacturer data is submitted from protocol-driven clinical trials, which are closely monitored under ideal conditions. Post approval, NICE will undertake ongoing assessment at regular intervals and if it finds that the negotiated patient access scheme or criteria differ from real-world outcomes, your product could get dropped from formulary lists. Therefore, it is critical to continue to communicate your product’s value throughout its lifecycle.

Having the right value communications strategy before, during and post-launch is vital for commercial success and maintenance of drug list position. The GLOBALHealthPR team has years of experience in England, the UK and EU markets, and can offer valuable insights to your marketing and market access teams.