NHS England lowers thresholds for direct oral anticoagulant IIF indicator

Please note: We published an incorrect version of this article on 19 April that did not reflect that the lower and upper thresholds for CVD-06 had been updated by the time of publication. We removed the article, and we apologise for any confusion caused

NHS England has reduced the thresholds for an Investment and Impact Fund (IIF) indicator that incentivises PCN practices to prescribe a specific direct oral anticoagulant (DOAC).

The indicator – initially communicated in a March letter sent to practices – specifies that GPs should start new patients onto edoxaban, and also consider switching patients where clinically appropriate.

Under updates to the 2022/23 Network contract (31 March), NHS England reduced the lower and upper thresholds for the CVD-06 indicator to 25% and 35% respectively, from 40% and 60%.

The draft figures had caused concern among some PCN clinical directors that the workload involved would be too great, but the lower thresholds have alleviated some concerns.

However, GP finance expert Dr Gavin Jamie still estimates the updated indicator will mean the average PCN of 50,000 patients would still need to switch around 180 patients onto edoxaban.

He added that the size of the task, which would yield on average about £69 per patient switched, varied around the country.

Dr Jamie said: ‘There are six CCGs who are already over that 35% threshold and should qualify for the full funding without changing prescribing with two – Norfolk & Waveney CCG, and Bedfordshire, Luton and Milton Keynes CCG – comfortably over 40% , although there may be some variation at the PCN level.’

He added: ‘However, we can say that Rotherham CCG, at 5%, will have to get about 30% of its patients, giving an effective payment per patient switched of about £50. This is still a significant rise on what had gone before.’

The IIF indicator was announced two months after NHS England entered into a national procurement agreement with several manufacturers – including those of edoxaban – with the aim that savings made would allow more patients to be diagnosed and treated.

However, some clinical directors have noted that although the lower thresholds are easier to meet, there will still be an additional workload to shift patients.

And others expressed concerns around the IIF indicator incentivising the use of a particular drug based on cost – although this is allowed under NICE guidance.

Dr Manu Agrawal, clinical director at Cannock North PCN, said that pursuing the IIF indicator would present GPs with an ‘ethical dilemma’, wherein clinicians may ask patients to change their medication ‘without actually having any clinical evidence behind it’.

He said: ‘What PCN CDs and practices are asking for is some evidence from NHS England to support informed shared decision making with patients to switch medications.’

Dr Saul Kaufman, clinical director for St John’s Wood and Maida Vale PCN, said: ‘Often what is not factored into these financial equations though is the time taken talking to patients about the switch by clinical and community pharmacists and also GPs.

‘I think basing decisions solely on cost with the input of clinicians isn’t a good way to make decisions about healthcare although I acknowledge that finance is an important consideration for medicines especially on a national level’.

One PCN clinical director in Greater London, who wished to remain anonymous, said that incentivising a particular drug, apparently based on cost-saving, sends ‘a clear message that the NHS is struggling’.

They said: ‘In many ways, it is also short-sighted as the pure workforce hours to change patients to edoxaban and the consequent disruption will likely generate a higher economic cost than any material saving.’

However, they highlighted that the primary concern for clinical staff will likely be how to determine which patients can safely be switched onto the drug.

‘The indicator could easily have been tweaked to recommend only new patients being initiated on the medication and this would have been much more palatable.’

Dr Shahed Ahmad, NHS England’s national clinical director for cardiovascular disease prevention said: ’Our national plan to accelerate the uptake of direct oral anticoagulants (DOACs) could see over 600,000 more patients receive treatment over the next three years, with the opportunity to prevent tens of thousands of stroke events.

’This activity has been clinically-led and in line with NICE guidance, NHS recommendations make clear that it is for the prescribing clinician to determine which DOAC(s) are clinically appropriate for an individual patient.’

NHS England declined to clarify why the thresholds were lowered.

The Pharmacist's sister title Pulse previously reported that the £14.8m funding attached to the indicator would equate to around £25,000 per average-sized PCN with 50,000 patients.

In an email bulletin sent on 21 April, NHS England announced its national plan ‘to accelerate the uptake’ of DOACs, recommending that clinicians should use edoxaban, where clinically appropriate.

The total expenditure on medicines in England by the NHS in 2020/21 sat at around £16.7bn, according to the NHS Business Services Authority.

According to OpenPrescribing, around 1.2 million prescriptions were made for DOACs in January 2022, around 13.5% of which were for edoxaban.

The commissioning recommendations for the national procurement for DOACs states that for patients commencing treatment for AF, subject to the criteria specified in the relevant NICE technology appraisal guidance, clinicians should use edoxaban where this is clinically appropriate.

‘If edoxaban is contraindicated or not clinically appropriate for the specific patient then, subject to the criteria specified in the relevant NICE technology appraisal guidance, clinicians should then consider rivaroxaban first, then apixaban or dabigatran.

‘For patients already prescribed a DOAC for the treatment of AF: subject to the criteria specified in the relevant NICE technology appraisal guidance, commissioners may wish to consider developing local policy to review patients currently prescribed apixaban, rivaroxaban or dabigatran, where clinically appropriate.’

Daiichi Sankyo, the manufacturer of edoxaban, refused to comment.

This article was initially published on our sister title Pulse.