Evidence from Coloplast – MT 26

Welsh Assembly Health and Social Care Committee inquiry into access to medical technologies in Wales.

Submission from Coloplast

October 2013

Introduction

Coloplast is a leading medical technology company specialising in intimate healthcare needs, developing products and services to make life easier for people with very personal medical conditions, including urology and continence care, ostomy and wound care.

As the users of our products have a variety of often very personal and private needs, Coloplast products are co-created with those who use them, empowering users and helping them to better manage their conditions. This “intimate healthcare” model means that we can better understand the needs of the people who rely on our products and how we can help them meet those needs.

Unsurprisingly for such intimately used products, major international surveys have shown that users of urology and stoma products want discretion, comfort and reliability: six out of ten male users of urinary catheters rank discretion as the number one feature they look for in a product.

We supply our products into the NHS, both into secondary care, and into primary care through Part IX of the Drug Tariff. This submission draws upon our experience of ensuring that patients in Wales are able to access medical technologies, including new and innovative products, and considers how policy chances could ensure better access to medical technologies within Wales.

How the NHS assesses the potential benefits of new or alternative medical technologies

The new arrangements under Part IX of the Drug Tariff for the provision of stoma and urology appliances – and related services – in primary care came into force in April 2010. These arrangements provide a national framework for these products in England and Wales, providing commissioners with a comprehensive list of all the products that must be made available to patients and what the prices are for each of these products. For products to be included on the Drug Tariff they must be shown to be safe and effective; appropriate for prescribing by GPs, or independent prescriber nurses and pharmacists; and cost effective.

This ensures that patients have access to all the approved products and commissioners can be sure that they are getting value for money.

The Drug Tariff also saves local commissioners time and resources by negating the need for local tendering processes and competitions. It ensures that all patients in all localities have equal access to every product, meaning that postcode lotteries do not occur, as they might otherwise – and GPs, Independent Nurse Prescribers and Independent Pharmacist Prescribers are all free to prescribe the most appropriate products for each individual patient.

This is incredibly important to people who use urology and ostomy products as the smallest differences in products can make a huge difference to a person’s wellbeing and independence. Two products may serve the same purpose but the attachments on one may be easier for a particular individual to use – therefore, with the right product they can change their devices independently, but with the slightly different product they need a nurse to attend on them three or more times a day to do it for them. Therefore, while the second product might save a little money for the NHS in the short run, it results in massive additional spend in the long run, not to mention being hugely detrimental to the patient’s wellbeing.

Often these implications are not taken into account because the budgets for one area of spending are totally separate from the budgets in another area of spending. By considering the impact on public spending as a whole, we can ensure that patients are able to access new innovations which can help to save money over the longer term.

The need for, and feasibility of, a more joined up approach to commissioning in this area;

The best method of improving access to innovative continence and ostomy products would be to improve the quality of continence services within Wales, so that patients are able to access comprehensive information and support, which enables them to understand the causes of their incontinence as well as find the best way to manage it for them.

In April 2013, a group of charities produced a document examining continence services in Wales, and calling on the Government and Local Health Boards to take steps to improve the quality of services. Particular issues which they highlighted include the fact that there are not enough specialist advisers or nurses to deliver continence services to the standards required; that patient don’t always know how to access services (including the fact that they can often self-refer) and that many GPs don’t have the required knowledge of the tests, investigations and expertise which are required to successfully manage incontinence. Additionally, the report found that many consultant urologists didn’t understand how underlying conditions such as spina bifida or spinal injuries could impact on continence.

This has led to a situation where patients are often given continence products, such as pads, rather than staff seeking to understand the cause of their incontinence and find the best possible solution which preserves dignity and leads to improved health outcomes.

A more proactive approach to identifying continence problems would help to improve the quality of service provided to patients and allow them to find the right product to manage their incontinence – allowing them to live as normal a life as possible. This could mean working with the patient to find a catheter which works with their limited dexterity, or for people with neurological conditions which lead to neurogenic bowel dysfunction, considering whether rectal irrigation would be the most appropriate way to manage their condition.

The financial barriers that may prevent the timely adoption of effective new medical technologies, and innovative mechanisms by which these might be overcome

One of the financial barriers which may prevent the timely adoption of effective new medical technologies is the focus which the NHS can have on making short term savings and simply comparing the cost of products – rather than looking at the value provided by a product and the benefits which it could provide for both patients and overall public spending in the long run.

As an example, the Drug Tariff provides an excellent national framework for the commissioning of urology and ostomy products. However, there have been instances where Local Health Boards have circumvented the Drug Tariff by introducing formularies, which limit the types of products that GPs and other prescribers are able to prescribe to patients. A formulary features a reduced number of products from the Drug Tariff and instructs or encourages prescribers to prescribe form that list.

The purpose of this is to bias prescribing towards cheaper products and away form more expensive ones. While officially patients are still able to be prescribed off-formulary products from the wider Drug Tariff list, this requires a level of information on the part of the patient (and often of GPs and nurses) which it is unreasonable to expect. In addition, the formulary, and the fact that often prescribers are only given information and training on the products list on it, makes it less likely that the prescriber will be able to direct the patient properly to alternative products. This increases the likelihood of patients being directed towards unsuitable products, potentially leading to more money spent and worse outcomes for patients.

In short, because often the short term goal of reducing the cost of prescribing continence care products is given precedence over the long term goal of maintaining patients’ independence and improving their wellbeing, the NHS is being burdened with unnecessary additional costs.

We are aware that this practice is much more prevalent in England than it is in Wales, and we are keen that patients in Wales continue to be able to access a wide choice of products.

Coloplast – Innovative Healthcare in the UK

Stoma products – the benefits of Peristeen in managing faecal incontinence

Coloplast developed Peristeen, a major innovation in bowel irrigation, which helps patients with faecal incontinence by introducing lukewarm tap water into the bowels using a rectal catheter. Other options for individuals with faecal incontinence included enemas, laxitives, and suppositories. For some patients, manual evacuation is used, which can take several hours and has obvious implications for the dignity of patients. Peristeen allows a quicker, more dignified method of bowel management leading to reduction in faecal incontinence, reduction of constipation and increased independence.

While Peristeen is more expensive than comparable products such as laxatives, it can save money in other areas, including reduction in nursing time required (for some patients from seven days a week to one day a week). There is also evidence of reductions in urinary tract infections for those using the products, something which also has large cost implications. It also allows people to live more independently, meaning that they are able to manage their own care and may be able to return to work, creating huge savings for the welfare system, which are not factored into health budgets.

Urology products – the evolution of catheters for managing urinary incontinence

Coloplast has consistently driven forward developments in urinary catheters which improve usability and dignity for patients. In 1993, we produced the EasiCath, which allowed patients to simply add water rather than adding their own lubricant. In 2000, we introduced the SpeediCath, which was ready to use straight from the packet without any need to add water. In 2003 came the SpeediCath Compact for Women, which was smaller than normal catheters and designed to provide extra discretion. In 2011, we produced the SpeediCath Compact Male, the most compact male intermittent catheter on the market today. The product is extendable, which means it is half the size of traditional catheters whilst in its packaging. The product is pre-lubricated and ready to use – with the same functionality, hygiene and quality as the best full-size catheters on the market. All of these new devices represented a step forward for users of catheters, which allowed them to be that bit more independent and to further increase their privacy and dignity.

Conclusion

Medical technologies play a vital role within the Welsh health system, and with thousands of people within Wales relying on continence products as part of their day to day lives. If patients are able to access the right products to meet their individual needs, this can help increase their independence, dignity and participation in social and economic activities. However, not all patients are able to access the products which would help them to achieve the best health outcomes. To help improve this situation, we recommend that the Welsh Government should:

Ø Work to improve the quality of continence services to ensure that people are getting access to proper advice, from people with a real knowledge of different conditions and the products which can be used to manage incontinence.

Ø Consider the value of products, rather than just the cost – so that the full lifetime benefits of a product are being considered, and the country feels the benefits of innovation.

Ø Don’t make use of local arrangements which undermine patient choice and prevent patients from accessing innovative, high quality products.