Manchester's devolution revolution: will pharma get a seat at the table?
Greater Manchester is blazing a trail with integrated health and social care, in the midst of a funding crisis. Can it succeed – and will pharma get a seat at the table?
Greater Manchester is just months away from launching a bold experiment, aimed at creating an integrated, locally-controlled health and social care system fit for the 21st century.
From April 2016, a coalition of local authorities and NHS organisations in and around North West England's biggest city will take control of a combined health and social care budget of £6 billion. It represents the biggest shift so far towards integrated care in England, backed by NHS leaders and healthcare experts as the best way – perhaps the only way – to deal with the challenge of ever-growing demand for care from an ageing population.
Health and social care users increasingly have complex, long-term conditions which require joined-up services. The Conservative government has pledged that the project – commonly known as Devo Manc – can radically improve health for the region's population of 2.8 million, and help eliminate costly waste at the same time.
However not everyone is convinced that the experiment will work, and a number of concerns have been raised. First of all, critics say the scheme is politically motivated, being the brainchild of Chancellor George Osborne, rather than coming from NHS England. Second, there are fears that the rushed nature of the project, and the complexity of getting disparate organisations to realign, will prove to be too much, too soon.
Finally, while Manchester's NHS and local authority leaders have embraced the idea, the biggest concern is that a growing national budget crisis in the NHS and social care will scupper the whole project.
Is pharma part of the picture?
So as Greater Manchester hurriedly prepares for April 2016, what impact will it have on the use of medicines, and the role of the pharmaceutical industry?
Answers to these questions are, to date, thin on the ground. As a whole, pharma is keen to play its part in the process, but has had little indication from the devolution leaders on how they view the sector's role.
The best-case scenario would be the pharma industry interacting with one single, holistic system, with medicines seen as a long-term investment in creating a healthier society.
The worst-case scenario would see pharma shut out by a new organisation keen to flex its muscles – and one which could even seek to break away from the national standards of the NHS.
Some industry executives say the early omens from Greater Manchester aren't good, with one telling pharmaphorum the region was making 'draconian, paternalistic' noises, threatening to restrict all of its decisions on paying for medicines to a very small market access group.
There has even been speculation that Greater Manchester could opt out of following NICE guidance – a move which would, at a stroke, make pharma's job far more difficult in the region.
Despite these concerns, most in the industry know that Greater Manchester may indeed be the shape of things to come for England, and want to help make the project work.
Devo Manc was one of the topics covered at the recent IMS Health 'Future Health Insights' roundtable event in London, which focused on ways in which health inequalities across England could be addressed.
Lis Cook, business development director at Ferring Pharmaceuticals, said her company was particularly interested in joint working with the NHS on 'win-win' projects: those which could improve patient care, cut NHS costs and help increase access to medicines.
Cook stated that Greater Manchester had great potential to foster such projects, as it would be able to take a much more 'joined up' view of health and social care.
However Greater Manchester's organisation is still taking shape, and has little time to put in corporate governance before April 2016, including clarifying rules on industry engagement.
Lis Cook said this was a concern.
"We can only contribute if we have a place at the table. But at the moment there is no mechanism for including us – that's what worries me."
Cook pointed out that her company had a very successful joint working project with one local Clinical Commissioning Group (CCG), NHS Cannock Chase CCG. This centred on increasing local use of the calprotectin test, a low-cost diagnostic which helps doctors differentiate between Crohn's disease, ulcerative colitis or irritable bowel syndrome. She explained that its use had helped the CCG save £250,000 – but nevertheless Ferring still had difficulties in getting other CCGs to adopt the test.
This example illustrates the potential of working with local NHS organisations, who can act more swiftly – but also the limitations when proven interventions are not taken up across the country.
Chris Beckley, market access director at Almirall, was also at the event, and said his company was interested in forging real partnerships with the health service.
"Devolution is a step change in how healthcare is going to be delivered in this country," he commented. "We hope that the leaders of this change recognise that the pharma industry has a role to play in helping them meet their objectives."
He stressed that developing a mutual understanding and trust between pharma and the NHS was vital.
"All change can be good change, provided it is inclusive. But at the moment the pharma industry isn't necessarily being included in discussions around devolution," he stated.
Pharma companies needed to communicate with a range of healthcare professionals, not just the budget holders, to make sure the medicines were reaching the right patients and were being used properly, he concluded.
Also contributing to the roundtable event was David Watson, the ABPI's head of commercial and PPRS. He said the ABPI views Greater Manchester and devolution as a great opportunity for industry and the NHS to engage at a local, regional and national level.
Companies are looking to another initiative, the ongoing Accelerated Access Review (AAR), as a way of tying together all of the disparate, and often disjointed, projects in the UK market. The AAR released its interim report a few weeks ago, advocating a raft of changes, including tilting the entire system towards a 'conditional yes' approach to faster drug access.
David Watson said he hoped the AAR could be a positive force for bringing the NHS and industry together.
"If the AAR addresses one thing, it will give both sides a wake-up call to say you've got to work together to solve these things," he commented.
Can Greater Manchester opt out of NICE guidance?
Despite this optimism, the rapid evolution of the devolution model has thrown up lots of questions about how it will work. The Greater Manchester Medicines Management Group (GMMMG or 'G triple M G') is already established as a key decision maker for market access in the region.
If the GMMMG becomes more powerful, it could raise concerns about a new tier of regional decision-making, adding to market access barriers.
Most alarming for pharma is the suggestion that Greater Manchester may seek to opt out of following NICE guidance. NICE recommendations currently carry mandatory status in England's health service, and an opt-out would undermine NICE's guidance on new drugs, which the industry relies on when talking to regional NHS decision makers.
The UK industry would resist any such opt-out, and will hope the AAR prevails in creating a more joined up, rather than fragmented, environment in the UK.
A more encouraging sign that the region is serious about bringing in new technologies and thinking is Health Innovation Manchester. Launched in September, this brings together a cross-section of local organisations, and aims to put innovation at the heart of the initiative and engage directly with life science firms.
Greater Manchester's challenge
There is little doubt that Greater Manchester will be under huge pressure to deliver tangible improvements whilst creating a corporate governance structure on the hoof.
The region's coalition needs to bring together no fewer than 37 different organisations – including ten Greater Manchester councils, 12 CCGs and NHS and Foundation trust hospitals.
A new shadow governance structure, led by chief officer Ian Williamson, began work on 1 October, and has now set out its strategic plan.
The partnership aims to launch its five-year plan for health and social care in December.
The largely urban region is socially diverse, but has pockets of deprivation and its average life expectancy for both men and women is almost two years below the average in England.
Ian Williamson told a recent King's Fund Integrated Care Summit that the Greater Manchester group aims to show major health improvements for the region by 2020, including reducing the number of people with chronic conditions by 64,000, and cutting visits to urgent care by 10 per cent.
Plans for devolution don't stop at Greater Manchester, with the more rural Cornwall region also pressing ahead with its own plans. Devon and Somerset have also expressed interest in greater powers over public services, and London looks set to launch its own health devolution pilots in the near future.
Time and money in short supply
Dr Kailash Chand is deputy chair of the British Medical Association and a general practitioner in Tameside in the Greater Manchester region, so is acutely interested in the success of Devo Manc.
Speaking at a recent event reported on by the Manchester Evening News, Chand said he believed the reforms had great potential to offer real benefits to patients, in particular "genuinely patient-centred and genuinely co-ordinated care."
However he warned, "But the evidence tells us that delivering this will be tough. Very tough. Complex integration takes time and patience to deliver results. And given the efficiency demands being placed on the health system currently, we might say time is short."
Perhaps even more worrying than the lack of time is the shortage of money. There are growing warnings of financial crisis, with predictions that NHS in England will record a deficit of £2 billion this financial year. In Greater Manchester, six out of nine of its hospital trusts are predicting a loss.
Against this background, introducing new approaches and structures will add further stress to the system. On 25 November, George Osborne announces his government spending review, and Greater Manchester has already put in a request for additional funding. The region will hope that it will get enough time and money to make the experiment work – so that it can blaze a trail not just for its population, but for all patients and the whole of the NHS in England.
Further reading
Manchester united? The road to devolution BMA blog, 28 September 2015
AAR: 'conditional yes' deals will speed innovation uptake 28th October 2015
Greater Manchester Health and Social Care Devolution (official website)
About the author
Andrew McConaghie is pharmaphorum's Managing Editor.
He can be contacted via Andrew.mcconaghie@pharmaphorum.com
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