World Antimicrobial Awareness Week is celebrated annually. This year’s event (18 to 24 November) has prompted me to reflect on a vital project I’m involved with to develop and test innovative models for the evaluation and purchase of antimicrobials. Working alongside NHS England & NHS Improvement and the Department of Health and Social Care (DHSC), the project team has been making strong progress. I’m impressed by everyone’s collaborative approach and the determination of colleagues across the partner organisations to progress this work. We’ve all drawn inspiration from the high level of international interest and the importance of the topic. So, what’s it all about?
The World Health Organization highlighted antimicrobial resistance (AMR) as one of the 13 urgent health challenges for the next decade. Unchecked, AMR threatens many of the United Nation’s sustainable development goals including those affecting health, food security, trade and labour supply. The pathogens that cause many common diseases – such as tuberculosis, urinary tract infections and food poisoning – are already at a concerning level of resistance to a wide range of antimicrobial medicines.
At the same time as pathogens are becoming increasingly resistant to our existing antimicrobial medicines, not enough new antimicrobials are being developed to replace them. The global pipeline of antimicrobials in development is woefully inadequate. Pharmaceutical companies see investment in novel antimicrobials as commercially unattractive resulting in market failure. New products active against priority pathogens should be subject to strict stewardship and used on a last-in-line basis. In the absence of significant outbreaks of drug-resistant infections, sales could be minimal. Other new products, offering alternative options to existing antibiotics, could be valuable as part of stewardship regimes. But these tend not to be used due to their high cost compared to existing products, many of which are generics.
A new approach
Our project aims to demonstrate the feasibility of a ‘subscription-style’ model that pays companies upfront for access to their antimicrobial products. Rather than paying for antimicrobials per packet, companies would be paid an annual fixed fee. We would base this on the value of their antimicrobial to the NHS, estimated through a NICE-led health technology assessment (HTA). As a result, the NHS would have new treatment options to call on when needed, while companies would be able to reliably forecast their return on investment.
Estimating the full value of an antimicrobial is complex and has not been attempted before. Currently, most HTA frameworks, including NICE’s, focus on the benefits received by individuals treated and sometimes their carers. For antimicrobials, the public health benefits go beyond the benefits to the patients treated. For example, effective antibiotics are essential in:
- enabling surgery and other medical procedures (enablement value)
- reducing the transmission of infections in the wider population (transmission value)
- providing a range of treatment options in case existing antimicrobials fail (diversity value).
Our project will test an adapted HTA which seeks to encompass these elements of value. We’ll apply a framework, developed by the DHSC Economic Evaluation Policy Research Unit, to capture value across the different attributes.
A global challenge
The UK represents around 3% of the global market for antimicrobials. This project alone cannot solve the issues within the global antimicrobial pipeline. For our work to have the full effect, we need other countries to offer similar incentives in their own domestic markets. Collectively, this could achieve a meaningful incentive for global investment. Sharing learning from this project with international stakeholders is an important part of our approach.
We’re testing the model on 2 antimicrobial products. Full roll-out will depend on the outcome of this pilot. It’s important we evaluate the model thoroughly before considering changes to routine commissioning.
We expect that we’ll have selected the 2 antimicrobials for the project before Christmas. We’ll then carry out the health technology assessment stage throughout 2021. Wish us luck!
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