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Drug shortages and "Price Concessions" - how much is it costing the NHS?

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There has been an interesting and concerning story in The Times today regarding shortages on a number of commonly-used medicines and a corresponding increase in the costs.

Here at OpenPrescribing we have been taking a look at these data as well, and trying to estimate to the cost to the NHS this year.

As the Times article suggested, the excess costs are now hitting £50m per month, with £175m extra spent in primary care by September:

Where is this happening?

This is happening all over the country. As most of these drugs are commonly used, CCGs are likely to be affected equally, and therefore big CCGs, such as NEW Devon and Cambridgeshire & Peterborough have the biggest excess costs. The top 20 affected CCGs are:

CCG Excess costs (April-September 2017)
NHS NORTHERN, EASTERN AND WESTERN DEVON CCG £3,107,829
NHS CAMBRIDGESHIRE AND PETERBOROUGH CCG £2,578,054
NHS DORSET CCG £2,538,271
NHS LIVERPOOL CCG £2,429,095
NHS NENE CCG £2,285,420
NHS BIRMINGHAM CROSSCITY CCG £2,238,652
NHS MANCHESTER CCG £2,207,458
NHS GLOUCESTERSHIRE CCG £2,002,603
NHS OXFORDSHIRE CCG £1,917,796
NHS NEWCASTLE GATESHEAD CCG £1,790,576
NHS SHEFFIELD CCG £1,774,936
NHS COASTAL WEST SUSSEX CCG £1,772,899
NHS SOUTHERN DERBYSHIRE CCG £1,762,552
NHS SANDWELL AND WEST BIRMINGHAM CCG £1,742,432
NHS KERNOW CCG £1,731,527
NHS SOMERSET CCG £1,703,823
NHS WEST HAMPSHIRE CCG £1,672,968
NHS HERTS VALLEYS CCG £1,643,472
NHS COVENTRY AND RUGBY CCG £1,590,756
NHS EAST AND NORTH HERTFORDSHIRE CCG £1,570,427

What drugs have had the biggest impact on cost?

The biggest cost impact between April and September 2017 was sumatriptan, a medicine used to treat migraines. In April 2017, before the stock shortages, a pack of six tablets cost about £1.35. This rose to £31.85 in June. Overall, the increase in costs has cost the NHS an additional £17.4 million between April and September.

The 20 drugs that have had the highest increases in cost since April are:

Presentation Excess Cost
Sumatriptan 50mg tablets £17,418,879
Olanzapine 10mg tablets £12,853,700
Gabapentin 300mg capsules £9,325,831
Quetiapine 100mg tablets £9,137,526
Quetiapine 25mg tablets £8,912,723
Mefenamic acid 500mg tablets £8,758,719
Levetiracetam 500mg tablets £8,720,187
Sumatriptan 100mg tablets £6,256,685
Quetiapine 200mg tablets £6,195,682
Olanzapine 5mg tablets £5,998,957
Olanzapine 20mg tablets £5,906,217
Levetiracetam 1g tablets £5,706,337
Quetiapine 300mg tablets £5,686,717
Amlodipine 5mg tablets £4,377,306
Terbinafine 250mg tablets £3,951,535
Betahistine 16mg tablets £3,591,791
Sodium cromoglicate 2% eye drops £3,516,736
Olanzapine 15mg tablets £3,486,081
Levetiracetam 250mg tablets £3,426,838
Amlodipine 10mg tablets £3,049,626

Is it getting better or worse?

The short answer is, we don’t know. Although we only have prescribing data up until September 2017, we’ve estimated the costs for October by mapping September’s prescribing data to the October “price concessions” list. This has increased to 84 lines, including common drugs such as amlodipine for blood pressure (27.3million prescriptions in last 12 months) and citalopram for anxiety and depression (14.3million prescriptions in last 12 months). Our estimate is that the excess cost for October will be £56 million, putting the total increase in costs so far since April 2017 at £233 million.

For prescriptions dispensed in November, the situation is more confused. The Pharmaceutical Services Negotiating Committee (PSNC) have requested price concessions for 97 items (the highest yet). However, as of today (7th December) the Department of Health have only granted 38 of these. This has led to the strange situation where community pharmacists don’t yet know what they will be reimbursed for the drugs they have purchased and supplied to patients last month.

Why has it happened?

It’s not clear. There have been various reasons discussed, including Brexit, stock shortages, and suggestions that wholesalers have been holding back stock. What’s certain is that the partial removal of manufacturing authorisations from Bristol Laboratories and Dr Reddy’s manufacturing plants hasn’t helped.

What happens when drugs are no longer in short supply?

Often when a price concession no longer applies the price returns to what it was before the shortage. But increasingly this is not the case, and the “Drug Tariff” price increases to near the “price concession” value. For example, olanzapine 10mg tablets, an anti-psychotic, which has increased from £1.09 to £21.95 a pack. If this price stays the same, the NHS will spend about £27 million per year on all generic olanzapine tablets, compared with about £2m last year.

Ropinirole 2mg tablets, used to treat Parkinson’s Disease, was £2.66 a pack. It is no longer listed as a price concession, but its pack per price has increased to £16.37.

We’ve been working on a Drug Tariff viewer (which the images above are from), which will allow users to see graphs of cost trends on any drug listed in the tariff. Check the blog, our Facebook page or Twitter in the next few days to see when it’s available. (EDIT 11th December: the Drug Tariff viewer is now available. Read more about it here.)

We are also working on further analyses to help CCGs and pharmacists identify and understand this issue better.