Rotherham Nicotine replacement therapy voucher scheme: options appraisal

Transcription

1 Rotherham Nicotine replacement therapy voucher scheme: options appraisal Board Meeting 16 July 2012 Author(s)/Presenter and title Sponsor Director Alison Iliff, Public Health Specialist, NHS Rotherham John Radford, Director of Public Health, NHS Rotherham Purpose of Paper To seek approval from the NHS SYB Board to amend the free nicotine replacement therapy (NRT) voucher scheme in Rotherham. This proposal is supported by Rotherham Metropolitan Borough Council. The paper has previously been to the Rotherham Clinical Commissioning Group Committee for information. Key Messages/Issues The current NRT vouchers scheme is overspent and rising costs are unsustainable. This paper explores the issues and offers some solutions for ongoing management based on the evidence of what works and sustainability of the service. Recommendations That the Board approve Option 4: reduce the offer to a single type of NRT per voucher (transdermal NRT patch). That the Board note that a full range of NRT treatments continue to be available via FP10. Background (Brief Summary) The current nicotine replacement therapy (NRT) voucher scheme provides 12 weeks free NRT to people quitting with the Stop Smoking Service, pharmacies or dentists. The scheme is time consuming to administer, expensive to provide, and costs are increasing with increasing numbers of quitters and product range. There has been a history of over-prescribing and waste (returns of unused products to pharmacies) in pursuit of higher quit targets. 1

2 The benefits of quitting are only realised when somebody quits on a long-term basis. The Rotherham Stop Smoking Service currently estimates 20% of its 4-week quitters are still non-smokers at one year. This would equate to about 550 people quitting long-term with NHS support in Rotherham, of which c400 would have had access to the NRT voucher scheme. For those entitled to free prescriptions NRT or other stop smoking products are available free of charge via a GP prescription. NRT is available through patients GPs subject to prescription charges or is available over the counter in pharmacies. The main advantage of operating an NRT voucher scheme is patient convenience cutting out the need to go to the GP for a prescription; this was thought to increase quit rates. This is the final year of NHS 4 week quitter targets; the New Public Health Outcome Framework uses population prevalence as a measure of tobacco control. The overall strategy for tobacco control and the method and scale of provision of stop smoking services is under review across South Yorkshire in partnership with SCHARR. The clinical evidence base for the success of Nicotine Replacement Patches is clear, however this clear choice of market leading delivery mechanism is increasingly being eroded by a choice of more complex delivery modes and drug therapy all at an increased cost and all heavily marketed by pharmaceutical companies. Analysis of Risks The risks of each option are given alongside its description. Equality Impact: Currently the voucher scheme is only offered to people quitting with the NHS Stop Smoking Service, with a pharmacy or dentist. Those quitting with general practice support must obtain their NRT via a prescription or by purchasing the products over the counter. 2

3 Rotherham Nicotine replacement therapy voucher scheme: proposal to alter the scheme Board Meeting 16 July NHS Rotherham currently runs a nicotine replacement therapy (NRT) voucher scheme for people who are attempting to quit smoking with NHS support from the Rotherham NHS Stop Smoking Service (RSSS), pharmacies or dental practices that provide the enhanced service for stop smoking support. People who quit with support from their GP practice through the enhanced service do not have access to vouchers. Vouchers are only provided for people who are registered with a Rotherham GP. 2. NRT vouchers are issued to provide twelve weeks supply of a specified range of NRT products free of charge to people trying to quit smoking through RSSS, pharmacies or dentists. Each voucher covers a two week supply and is completed by the stop smoking advisor in consultation with the person quitting. Each person can be given whatever NRT products needed to complete their quit attempt. 3. An agreement is in place with some pharmacies for redeeming the vouchers. The pharmacy is paid for the cost of the products supplied plus a dispensing fee. 4. The budget for the NRT voucher scheme has been increasing as the number of people making quit attempts has increased, and in 11/12 was significantly overspent. The cost of fulfilling each voucher is increasing as new and more expensive products come onto the market; the average voucher cost rose by 1.00 between the first and last six months of the year in 11/12. When over 11,000 vouchers are issued each six months this apparently small increase has a significant impact on budget. 250,000 is in the budget line for the NRT voucher scheme in New research published in the British Medical Journal in March 2012 showed that offering free NRT in addition to standard care on the NHS quitline does not improve quit rates (BMJ 2012;344:e1696). This would appear to be borne out by the local data (Table 1), which shows minimal difference in quit rates between the stop smoking service and pharmacies, which issue free NRT, and GP settings, which don t. For patients attending GP practices to stop smoking, issuing an FP 10 acts like a voucher. The Rotherham Quit Smoking service is increasingly offering a quitline type service as a cost effective method of quit support. 3

4 Table 1: Quit rates by intervention setting (source: DH quarterly return data) Quit rate GP setting 51% Stop Smoking 49% Service Pharmacy 45% Q1-Q3 GP setting 49% Stop Smoking 52% Service Pharmacy 46% 6. We propose six options for continued management of the NRT voucher scheme for the Board to consider: Option 1: withdraw the scheme in its entirety. This option would involve discontinuing the NRT voucher scheme in a managed process over the next 3-4 months. The current agreement with the pharmacies that fulfil the vouchers would require three months notice to be given to discontinue the scheme, which would also allow us time to notify all the advisors on the local enhanced service and the specialist service that they should stop issuing vouchers for new quit attempts and enable pharmacies to run down stock levels. Anybody who has started a quit attempt with the offer of free NRT would continue to receive the vouchers until their quit attempt ceased. Pharmacies make little, if any, profit on this scheme and would be able to increase over the counter sales if free supplies are no longer offered. Risks: this original proposal has been vigorously opposed by the local Stop Smoking Service, who have lobbied local politicians and the media, and have sought support for their arguments from the authors of the BMJ article. Continuing to pursue a complete withdrawal of the scheme could therefore bring some reputational risk to NHS Rotherham and RMBC. There may be reduced access to the specialist service and a reduction in their quit rates if quitters switch to General Practice provision. Advantages: frees up substantial financial resource for other tobacco control measures. Option 2: continue the scheme as is We make no changes to the voucher scheme and continue to offer 12 weeks free NRT to all those making a quit attempt. Risks: The existing scheme is financially unsustainable given increasing quit attempts and increasing product cost. The average voucher value in the second six months of the year was 1 higher than in the first; if this were replicated throughout 12/13 the budget would again be overspent, even with no additional quit attempts. 4

5 Option 3: introduce a prescription charge per item for those people who do not have access to free prescriptions This arrangement was in place when the voucher scheme was developed. However, the majority of those making a quit attempt were entitled to free prescriptions and as a result of the few paid-for vouchers errors frequently occurred in pharmacy and in the processing of the vouchers. Risks: The impact on spend would be minimal and create an additional administrative burden. Option 4: reduce the offer to a single type of NRT per voucher (transdermal patch) Most vouchers are dispensed for a long-acting form of NRT (a patch) and a shortacting product. If only patches were offered free a significant saving on the budget could be made. In 11/12 the spend on patches was and 21, on the associated dispensing costs. If only patches had been provided in 11/12 the spend would have been within the budgeted amount. Reducing the offer to a single item would nearly halve the current spend. Risks: People attempting to quit would be asked to purchase or be directed to their GP practice for any additional NRT products required to help overcome cravings. This could still result in some negative press as is the case when any free service is restricted/reduced. Option 5: reduce the offer of free NRT to eight weeks and a reduced range of products This would enable individuals making a quit attempt to continue to access long and short-acting NRT but for a reduced time period. Over the 12-week NRT programme offered in 11/12 23,000 items were dispensed. By reducing the offer to eight weeks, we could expect around 15,350 items to be dispensed at a cost of 171,306 (based on the average voucher cost Oct-Mar). Dispensing costs would be approximately 25,020. We would also ensure that only the cheapest products in each format are offered (for example, there are price differences between some patches/gum of equivalent strength and pack size). Risks: this option would appear to offer the least risks, but could still result in some negative press due to the reduced length of provision. For options 2-5 we would also advocate transferring the budget to the Rotherham Stop Smoking Service (RSSS) and for the service to manage the prescribing within the allocated budget, giving them a greater sense of responsibility for appropriate prescribing. It would be RSSS s responsibility to establish a new scheme in line with a service specification and to deliver within budget. Reducing wastage by changing to a weekly voucher and reducing dispensing charges by establishing a direct supply could also improve the efficient management of the scheme. Any scheme would also have to be made available to stop smoking advisors within pharmacies and dentists who are not prescribers. RSSS would also have to establish and performance manage agreements with community pharmacies for the fulfilling of the vouchers. Their existing IT system has the facility to manage a voucher scheme. 5

6 The preferred options are option 4 or option 5. Option 4 would create a greater saving; option 5 offers the least change from the current system and would therefore appear the least controversial. We would recommend Option weeks is the recommended length of treatment to achieve long term quitters and hence reduce prevalence. 7. Savings made through the alteration of the scheme would free up the funding for other Public Health priorities where there is better evidence of effectiveness. In 2012/2013 there would only a part-year effect in the savings due to the winding down period. 8. References Ferguson et al Effect of offering different levels of support and free nicotine replacement therapy via an English national telephone quitline: randomised controlled trial. BMJ 2012;344:e Alison Iliff Public Health Specialist, NHS Rotherham July