Drug treatments for Alzheimer's disease - the Scottish context for cost effectiveness analysis

On 22 November, NICE will publish its Multiple Technology Appraisal (MTA) for Alzheimer's disease drugs, limiting treatment to those in the moderate stage of the illness. On the same day, NHS Quality Improvement Scotland (NHS QIS) is due to issue its advice on whether the MTA is valid for Scotland. The indications are that NHS QIS intends to validate the MTA.

There are compelling reasons why NICE’s cost-effectiveness calculations are not valid for Scotland. Alzheimer Scotland believes that NHS QIS should not to validate the MTA until a cost-effectiveness analysis based on these Scottish factors has been carried out.

NHS QIS would in most cases expect to rely on the work carried out by NICE, but we believe that in this instance, because Alzheimer's disease almost exclusively affects those over 65 and because of their very substantial requirement for social care services which are differently funded in Scotland, such a reliance is inappropriate.

NICE’s basic cost-effectiveness model (although we believe it to be seriously flawed in the context of dementia) relies on certain economic assumptions. These inputs to the model have been based on English health and social care arrangements, yet there are significant differences in the funding and distribution of care in Scotland which would impact on the costs to be weighed against the costs of treatment, in both early and late stage Alzheimer's disease.

1. NICE based their model on the cost of Alzheimer's disease both to the NHS and to personal social services. There are significant differences in Scotland:
Free personal care means that the cost to the state of care at home is higher in Scotland. By keeping people independent for longer, drug treatment in early dementia postpones entry to the ‘pre full-time care’ state in NICE’s model. The higher cost to social services in Scotland of care for those in the ‘pre full-time care’ state will have the effect of shifting the balance of cost effectiveness in favour of drug treatment in early dementia in Scotland compared with England.

• Of the 40,839 home care clients over 65 receiving free personal care, at a total cost of £135.7m , approximately 16,500 (40%) are people with Alzheimer's disease, at an estimated cost of £54.8m, or £3,323 per person pa.
• This compares with the average cost of a year’s treatment with the acetylcholinesterase inhibitor drugs of £1,010.

2. In the case of people who enter the severe stage of the illness, once again the cost-effectiveness threshold for treatment which could keep them for longer in the ‘pre full-time care’ state, postponing the need for long stay care, will be different in Scotland. As the recent Joseph Rowntree report on the sustainability of free personal care pointed out, ‘shifting the balance of care towards care at home can dramatically reduce costs: the average costs of care at home are less than the £145 and £65 for personal and nursing care in a care home’

• While the average weekly care home fee in Scotland of £446 is within the range of £355-520 used by NICE for the cost of institutional care, free personal care means a higher proportion of this is met by the state in Scotland. NICE used a figure of 70% for the proportion of the cost of institutional care met by the NHS and personal social services. This figure should be recalculated for Scotland.
• The pattern of care differs in Scotland from that south of the border. There is a larger proportion of people with dementia occupying hospital beds, which are significantly more expensive than care home places (the average cost is £1,271 per week for geriatric psychiatry ). In 2006 the average number of occupied beds was 2,520 psychiatry of old age beds and 2,364 geriatric medicine long stay beds . In England, with ten times the number of people with dementia, the average number of occupied mental illness elderly long stay beds in 2005-2006 was 2,909 .
• Access to treatments for people with severe Alzheimer's disease can play a key part in sustaining people for longer at home; the findings of Alzheimer's Europe’s Dementia Carers Survey highlight the fact that cognitive problems are not the most problematic for carers; rather, it is difficulties with activities of daily living and with behaviour which are hardest for them to cope with, and thus most likely to lead to the need for long stay care.

These differences seriously undermine the validity for Scotland of NICE’s cost-effectiveness calculations and point to the need for a specifically Scottish analysis.

Treatments in early dementia in particular contribute towards Scottish Executive priorities. Delivering for Health set out the keys to managing long-term conditions, including involving people in their own care and providing care in the least intensive setting. Without early treatment, people with early Alzheimer's disease will have a severely limited ability to participate in self-management of their condition and will need more intensive support. Their ability to participate in the important processes of patient/service user involvement will also be reduced and in many cases lost altogether.

Reducing health inequalities is also a key theme of Delivering for Health. Scotland lags well behind England in healthy life expectancy. Offering people with Alzheimer’s disease these treatments is an opportunity to contribute to increasing the healthy life expectancy of some of the 10,000 people in Scotland with early stage Alzheimer’s disease. Failure to offer them will undermine the principle of the NHS in Scotland that treatment should be based on clinical need and not the ability to pay. Those who can afford to do so will pay for the treatments, increasing health inequality.

The separate paper, A Scottish way forward for drug treatment in early Alzheimer's disease, sets out further Scottish evidence on the costs and benefits of treatments for early Alzheimer's disease.

The estimated current cost for treating mild Alzheimer's disease is £2.84m, less than 0.3% of the total NHS drugs budget. Alzheimer Scotland believes that this is money well spent.

Alzheimer Scotland has asked the Health Minister to ask NHS Quality Improvement Scotland not to confirm the anticipated NICE guideline until the above Scottish differences with the rest of the UK have been examined rigorously.