Analysis and insight from HSJ, today focusing on coronavirus covid-19 developments for healthcare leaders.

The cost of coronavirus

Clinical commissioning groups may be left to pick up the increased cost of drugs resulting from shortages caused by coronavirus— and that is just a flavour of the financial impact about to hit the health service.

In recent years shortages for other reasons — including Brexit— have pushed up the price of some generic drugs; and with global production and supply in question from covid-19, there is now scope for a similar or even bigger event.

In previous years, NHS England has ultimately agreed to pick up the tab. But new planning and contracting guidance last month said that, from April, CCGs would need to “make appropriate provision” to foot the bills themselves.

NHSE declined to comment on whether it intended to help CCGs with any drug price surge, and the Department of Health and Social Care said NHSE was responsible for CCG funding.

It is one example of the already mounting costs of preparing for and responding to the outbreak — ambulance trusts are said to be racking up large sums, while the number of cases is still relatively small. If and when it becomes serious, the costs will throw current financial planning completely off course.

Although mood music from the very top is positive — the prime minister has said the NHS will be “supported” on covid-19 — a number of senior finance sources told HSJ they had been given no clarity on where and when the money would flow, and how to account for it.

An industry insider has told HSJ: “Everything is going to be short, not just drugs.”

The reasons for global drug shortages are complex but in the past have been attributed in part to factories closing down across the globe, for various reasons, which reduced the volume of drugs that have been manufactured.

One pharma industry source said: “We have no idea if Chinese companies are still active.” Another told HSJ: “It takes six weeks for containers to arrive from China, we might see a market reaction if those stocks don’t leave.”

This week, India restricted the export of 26 pharmaceutical ingredients and drugs made from them, including paracetamol. While there are, conveniently, Brexit stockpiles in place — which firms have been told to keep in place — it is not clear how far these will get us.

One CCG medicines commissioning director said: “Two years ago, there was a significant increase in price concessions and NHS England did make dedicated allocations to cover that. This year it is now seen as a new part of the baseline.

“If the costs stay the same it is fair, but if it doesn’t, it is unfair. We haven’t put money aside to cover it as we cannot quantify or control the risk, and the day-to-day financial challenge is so significant that we are just trying to live within our means, we cannot afford a reserve. This could blow up in NHS England’s face.”

Another CCG leader said: “If coronavirus takes hold then all bets are off in terms of the planning round as the impact on staff and costs would be considerable, and that would apply in all areas. [Drug costs] are already giving us a problem as it’s not really being funded, so [coronavirus] just makes that worse.”

By Sharon Brennan

The first appointments cancelled

Harefield Hospital, part of the Royal Brompton and Harefield Trust, has become one of the first — if not the first — to cancel all routine face-to-face appointments because of coronavirus.

The hospital, which specialises in cardiothoracic surgeries and transplants, told patients it had taken the measure to protect them from catching the virus. Most of Harefield’s patients are either waiting for a life-saving transplant or are on a lifetime regime of medication that suppresses their immune system having already been transplanted.

One patient was told not to come if they were feeling well and instead to expect a consultation by phone in the next week.

The Freeman Hospital, also a major cardiothoracic transplant centre and part of the Newcastle upon Tyne Hospitals Foundation Trust, has also told patients not to come to routine appointments if they could only do so by using public transport, it is understood. Again, it has taken this measure to prevent the virus from spreading among its patients.

Harefield does very few routine elective surgeries but, in addition to transplant, they provide specialist heart operations to help patients survive until a suitable organ becomes available.

The news comes as the UK chief medical officer, Chris Whitty, told the Commons health committee on Thursday: “There are certain chronic conditions such as renal dialysis and chronic diabetes where we are concerned that those people are at higher risk.”

He said the NHS would provide “technical details” to doctors and nurses working in specialist centres so that they can tell their patients they “are in a group that need to think differently”. He did not provide a timeline for doing so.

Altruistic volunteers

Professor Whitty also used the committee session to warn older people, who also appear to be more vulnerable to the virus, not to self-isolate “at the moment as we do not think there is any advantage in doing so”.

He said: “One of the things we are trying to work out, is what we would advise and when to start [self-isolating].”

When this point comes, he revealed, Whitehall may call on the “remarkable altruism” of the public — in particular those who have already had the covid-19 virus — to help older people who may become isolated at home. He said: “I am thinking of what happens when people have already had the virus and are therefore not going to be infectious — what can they do?”

Digital triage

NHS England’s primary care medical director, Nikki Kanani, has written to England’s GPs to tell them to adapt their online booking systems to guard against a potential covid-19 patient turning up at the surgery unannounced. Practices will need to do online or telephone triages with patients that book online, to make sure they are not potentially carrying the virus.

The letter also told doctors not to prescribe more medicines than usual by extending the time covered by repeat prescriptions, or “support patients trying to stockpile”. Instead, they should consider putting patients on electronic repeat prescriptions, effectively creating year-long prescriptions that are divided into blocks. So, if a patient is on a month’s prescription now, a GP could prescribe 13 28-day supplies. This is to prevent strain on supply.

The centre will be distributing “an initial stock” of protective gear for GPs and practice staff next week, including 400 aprons, 300 pairs of gloves and 300 masks.