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Monitoring cost-avoidance by London providers from use of Patient Access Schemes for high-cost medicines

Patient Access Schemes (PAS) have been offered to the NHS by pharmaceutical companies since 2002 as a way of lowering the acquisition cost to the NHS of high-cost medicines without changing the (publicly available) list prices. PAS prices are confidential. The NHS benefits from significant cost avoidance, and patients benefit from improved access to new treatments. PAS are sometimes referred to as “risk share schemes” or “market access schemes”.

Monitoring cost-avoidance by London providers from use of Patient Access Schemes for high-cost medicines


There are several models for PAS and some are more complex and more labour-intensive for NHS pharmacy and finance staff to administer than others:

simple discount
• a cap on payment
• rebates dependent on response to treatment
• free-of-charge stock.

To be accepted for NHS use and to ensure that there is genuine net benefit to the NHS
after the costs of running the schemes are taken into account, most PAS are now subject to
approval by The National Institute for Health and Care Excellence’s (NICE) Patient Access Scheme Liaison Unit (PASLU) as part of their Technology Appraisal process.
All PAS models operate via one of two main mechanisms:

• ‘Price discount schemes’ – the pharmaceutical company passes on a straightforward
discount of X per cent on the price of the drug. This will be the price invoiced to the
organisation and no new internal process/mechanisms require implementation.

• ‘Manual managed discount schemes’ – an internal process/mechanism has to be
implemented in order to allow the potential cost avoidance to be realised. This may be
resource intensive and involve multiple departments within the organisation. This may have a negative effect on the uptake of the schemes.


Maximising uptake of PAS saves money by minimising acquisition cost. Data
collated in 2012/13 from one London trust showed saving/cost avoidance in
excess of £2 million in the financial year. As well as ensuring recovery of the
financial benefit, and enabling access to the medicine for patients, implementation of NICE-approved PAS underpins local compliance with NICE guidance and therefore with NHS England (NHSE) Commissioning policy.

In 2013/14, the LPP Medicines Optimisation & Pharmacy Procurement workstream initiated work to ascertain which PAS had been implemented by trusts across London and determine the associated cost avoidance in 2012/13. This was the first time any such exercise had been attempted in the NHS. Reporting any
identified discrepancies to individual trusts has helped to maximise the uptake of PAS, and therefore cost avoidance. For 2012/13 performance, only PAS for cancer drugs recommended through a NICE Technology Appraisal and routinely commissioned by NHSE were reviewed. For 2013/14 data, the scope was expanded to include non-cancer drugs as well as uptake of PAS associated with drugs paid for through the Cancer Drug Fund.

Method of data collection

1. For the straightforward discount PAS, data from the DH Commercial Medicines Unit’s (CMU) Pharmex database was used to check that the agreed PAS price had been paid.

2. The costs avoided by paying the PAS price rather than the manufacturers’ list price were calculated.

3. Complex retrospective discounting makes it impossible to do the same for manual discount schemes. Instead, a questionnaire was circulated to relevant pharmacy department leads at each trust asking for data which would allow us to calculate the approximate costs avoided by use of these schemes.


For reporting purposes, the data was divided into four broad categories: price
discount and manual discount schemes, and into cancer drugs, and non-cancer drugs.


2014/2014 Cancer PAS (CPAS) Non-cancer PAS (NCPAS) Total
Number of Trusts providing data (Surveys sent to 22 trusts) 18 16  
Expenditure on PAS drugs £66,316,919 £54,883,628 £121,200,547
Discount PAS
cost avoided
£15,565,627 £18,492,063 £34,057,690
Manual PAS
cost avoided (est.)
£8,771,616 £1,166,348 £9,937,964
Cost avoided (est.)
£24,337,243 £19,658,411 £43,995,654


Price discount PAS:

The majority of trusts had implemented the relevant PAS and paid the PAS price. Those that had purchased the drug but appeared not to have registered for the PAS were encouraged to ensure that future purchases were at the PAS price and in almost all cases losses were successfully recouped by retrospective claims to the supplier.

For the non-cancer drugs, monitoring for details of price discrepancies was not started until after the 2013/14 financial year end.

Manual discount PAS:

Costs avoided by use of manual discount PAS represented 93 per cent of the maximum theoretically possible. In almost all cases a valid reason for why a scheme appeared not to have been implemented was identified. In the majority of
cases this was that the trust did not treat the cohort of patients to which the PAS applied, but in a few cases, a missed opportunity was identified and trusts indicated that they would be pursuing the relevant scheme in the future.


This is the first and only monitoring exercise of this sort of which we are aware. Use of PAS for high-cost drugs for all London NHS hospitals in 2013/14, including drugs paid for through the Cancer Drug Fund, was reviewed by analysis of Pharmex data. High levels of uptake and cost-avoidance have been observed.

Any identified differences between the price actually paid and the anticipated discounted price were flagged. The data was validated by appropriate provider pharmacy staff. Reasons for discrepancies were also identified. In 2013/14, interventions were minimal because of lessons learned by trust pharmacy staff and the LPP MOPP team from the 2012/13 review. Quarterly monitoring of price discrepancies is now routinely undertaken.

The LPP MOPP team maintains a comprehensive database of PAS details which is regularly updated from information circulated by PASLU. The database helps to make sure provider pharmacy staff are aware of all relevant PAS updates from PASLU.

This work is now repeated annually and is reported widely to Chief Pharmacists of participating trusts, NICE PASLU and to NHS England.

Total costs avoided by use of Patient Access Schemes for high-cost medicines in London in 2013/14 were estimated at £44 million. This figure is likely to rise year by year as a steady stream of innovative, new, high-cost medicines is marketed to the NHS.

It is important to understand that these figures are evidence of costs already being avoided by providers who are paying prices accounted for in their business plans. These figures do not indicate new savings opportunities for providers or for commissioners.

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