As we look back on an unprecedented period in NHS history, what sort of impression did the pandemic leave on prescribing patterns? Wilmington Healthcare’s Oli Hudson lifts the veil on a new State of the Nation report to reveal an NHS transformed by the impact of COVID on services and pathways.
Prescribing offers a unique view of the NHS at any given point in time, revealing its many challenges, priorities and preoccupations. So, what can we learn from the prescribing patterns at the height of the pandemic?
That’s what our new State of the Nation report seeks to find out. Drawing on a raft of data from across primary and secondary care spanning the last two years, it paints an extraordinary picture of what actually happened to the NHS during one of the most turbulent periods in its history.
A transformation in delivery
First and foremost, the report highlights the scale and immediacy of the transformation in delivery across the NHS. Services were dramatically remoulded – virtually overnight in some cases – as restrictions and emergency protocols forced the NHS to remodel care pathways at break-neck speed.
Our analysis of the NHS’s Hospital Episode Statistics (HES) data shows inpatient spells collapsed from 17.3m in 2019/20 to 12.8m in 2020/21, as the NHS took dramatic steps to minimise patient footfall. Outpatient care saw a similarly stark redrawing of activity, with a 39% drop in in-person appointments and over a five-fold increase in telemedicine appointments.
With the exception of infectious disease – which saw an increase for obvious reasons – all therapy areas saw annual declines in admissions in 2020/21. Spells in oncology, gastroenterology, musculoskeletal, respiratory and ophthalmology all fell in 2020/21, undoing historic growth. Genitourinary and cardiovascular admission also fell, but not as sharply as the other major therapy areas.
Overall, our cost analysis shows the NHS spent between 12 and 51% less across all therapy areas in 2020/21 compared to the previous year.
Source: Hospital Episode Statistics (HES); NHS Digital
This operational shock left its mark on prescribing patterns too. In secondary care, mucolytics saw the sharpest percentage increase in costs in 2020/21, partly due to increased prescribing of the cystic fibrosis drug ivacaftor. Spend on ophthalmic preparations, meanwhile, fell by 14.6% as problems maintaining routine eye appointments in secondary care impacted spend on high-value treatments for wet AMD.
Antibacterials fell sharply too as prescribing of antibiotics continued to shrink – though this was potentially exacerbated by the reduction of inpatient admissions, which meant fewer non-COVID-related hospital-acquired infections. Drug areas associated with oncology and immunology provided the largest source of prescribing expenditure, showing their considerable cost burden on NHS budgets. Cytotoxic drug costs increased by 9.0 per cent to £1.8 billion in 2020/21, making it by far the largest single section in terms of prescribing costs.
Source: NHS Business Service Authority; Prescription Cost Analysis
In primary care, meanwhile, the largest area of expenditure was diabetes, which accounted for £1.2 billion of prescribing costs in 2020/21. However, by far the largest percentage increase in expenditure involved antidepressants, which rose by two-thirds (66%) to £371m in 2020/21: a reflection, perhaps, of the toll that the pandemic took on the nation’s mental health.
Source: NHS Business Service Authority; Prescription Cost Analysis
Winners and losers
Drilling down into specific drugs, the use of innovative treatments in secondary care remained strong despite the pandemic. Leading products were specialty medicines such as monoclonal antibody therapies, many of which are used to treat cancer or immunological indications. The NHS’s commitment to provide innovative therapies to address unmet patient needs is exemplified by the cystic fibrosis treatment ivacaftor, spending on which rose over three-fold to £393.9m in 2020/21. Other recently approved products, emicizumab for haemophilia A and asfotase alfa for hypophosphatasia, also saw costs increase by more than 200% in 2020/21.
In primary care, a different story unfolds. Unlike secondary care, the leading primary care products sat primarily within respiratory, cardiovascular and diabetes therapy areas. There was also a greater number of generic products. Anticoagulant therapies such as apixaban, rivaroxaban and edoxaban topped the spending charts, while respiratory products such as inhalable treatments for asthma and COPD were another significant area of spend.
However, the most dramatic change in primary care prescribing in 2020/21 involved the anti-depressant sertraline, which saw more than four-fold growth (305%). Statins, such as atorvastatin, and the GERD drug omeprazole also saw significant gains. All are suggestive of the strains that the pandemic placed on people’s lifestyles and ability to manage their conditions.
It is also worth noting the type of drugs that saw the biggest falls – in particular, there were notable dips in the prescribing of new, high value drugs in primary care during the peak of the pandemic. We can only speculate about why this may be – perhaps because some of these drugs are likely to need an acute sponsor which may have been more challenging during a period of restricted access to outpatient care. It may also be that GPs and/or area prescribing committees were more reticent to prescribe new medications at a time when primary care was less able to have regular, face-to-face contact with patients.
Two final data sets should give pharma food for thought. The first is the referral to treatment (RTT) waiting list, which ballooned from 4 million incomplete pathways prior to the pandemic to more than 6 million in November 2021. There is no better illustration of the magnitude of the backlog facing the NHS, and the enormous pressure on the health service to deliver.
The other is the regional variation in per capita spend on prescribing, which ranges from over £400 per person in the highest spending regions, to just over £200 per person in the lowest spending regions. Many factors are likely to be behind this, including demography, patient demands and expectations, clinical choice, differences in interpretation of guidelines, and the level of bureaucratic burden and financial stress within systems.
Whatever the cause, the scale of variation underlines the continuing disparities in population health management within the NHS. The importance of prescribing in managing both chronic and acute health conditions is well-known yet there are still stark variations in prescribing practice which means where you live continues to define how you are treated.
It leaves much to ponder, for both pharmaceutical companies and Integrated Care Systems, as they prepare for the future.
Download the State of the Nation report at https://wilmingtonhealthcare.com/state-of-the-nation/
Secondary care data is taken from the English Hospital Episode Statistics (HES) database produced by NHS Digital. Copyright © 2022, NHS Digital. Re-used with the permission of NHS Digital. All rights reserved.