The changing frontline: how to engage with England’s NHS in 2018

Wilmington Healthcare-pharmaphorum conference: England’s NHS is moving towards integrated care, and long-term outcomes-based contracts for medicines could become the norm

Just as most businesses begin to wind down for the year in the days before Christmas, the National Health Service is gearing up for the winter, its most challenging period.

And this year, the chancellor of the exchequer Philip Hammond has played the role of Scrooge: last month’s budget fell well short of the amount NHS England’s leaders said was necessary to maintain patient services.

NHS England’s chief executive Simon Stevens had asked for the £350m a week pledged by Brexit campaigners to be invested in the health service.

But instead, Hammond gave just £350m extra funding for the rest of 2017/18, part of an extra £2.8 billion in one-off funding for the NHS to cope with immediate pressures up to 2020.

NHS England says this won’t begin to pay for the increased demand on services, and its board has begun discussing which services will have to be deprioritised.

Against this background of a mounting financial crisis in England’s NHS, its leaders are trying to radically restructure the service to make it fit for purpose in the 21st Century, and also financially sustainable.

So how can the pharmaceutical industry understand and engage with the health service under so much pressure?

At the heart of the change is a fundamental shift to integrated primary, secondary and social care – a joining up of systems which are currently fragmented, wasteful and built around institutions rather than patient need.

I chaired the recent Wilmington Healthcare and pharmaphorum conference ‘The changing frontline: how to engage with regional NHS organisations’ at the King’s Fund in London, which brought together a group of four expert speakers to debate just exactly how this engagement could be achieved.

Change ‘At Scale and Pace’

Dave West is senior bureau chief, at Health Service Journal, a seasoned journalist who monitors this constantly changing picture. He says 2018 will see some rapid reconfigurations in England’s health service.

The vehicles for this change will be 44 new regional organisations called Sustainability and Transformation Partnerships (STPs). These are then expected to evolve into Accountable Care Systems will greater autonomy and integration of services.

At the moment, this shift is taking place without legislation because the government’s lack of an absolute majority and Brexit distraction means the law won’t be changed very soon. Nevertheless, the phrase being repeated by NHS England is change “at scale and pace .”

In 2018, this will include more and more of England’s current 207 local Clinical Commissioning Groups (CCGs) merging in order to save money.

[caption id="attachment_34129" align="alignnone" width="180"] HSJ's Dave West[/caption]

“Our estimate is that by April next year there will be 195 CCGs and more than half of them will be sharing chief executives across more than one CCG,” says Dave West.

There will also be pressure on hospital trusts to merge, although the complexity of this process means it will take longer.

While many of these mergers will be motivated by cost-cutting, West says more efficient and integrated systems will also yield savings.

“The light at the end of this very dark tunnel for NHS commissioners is the promise of medium to long term service change. If they can introduce upstream interventions, such as preventative services, and better integrated services, they will see their long-term costs reduced.”

He concludes that pharma needs to be aware of which areas are the early adopters of the ACS model in 2018, which are the financially troubled areas, and which regions are in the middle - as this will be reflected in their ability to work in partnership.

[caption id="attachment_34130" align="alignnone" width="180"] Steve How[/caption]

Steve How is Business Development Director, Wilmington Healthcare. He also sits on the board of Better Together, a Vanguard new model of care in Nottinghamshire.

Steve says there is potential for exciting opportunities for pharma to partner with these new models of care emerging around the country.

They are switching away from the Payments by Results (PbR) system, which has held back progress towards patient-centred care. This is being replaced by outcomes based contracts held jointly by the integrated providers within these new models of care . This de-silos budgets allowing for the introduction of new more efficient pathways and technologies to address the triple aim of the FYFV -better health, better care, and better value, including Nottingham and Nottinghamshire.

However, Steve makes it clear that money is very tight, and medicines are once again in the firing line.

“So where are the efficiency savings going to come from? Medicines is high up on the list and it's a bit of the easy win,” he says.

He says the big savings are coming from two programmes - Getting It Right First Time in secondary care and RightCare in primary care.

The prospect of NHS contracts, including medicines, managed within a 10-year contract is now feasible, however, even if it isn’t happening just yet. This is good news for pharma companies willing to enter into long-term partnerships, because medicines have a better chance of proving their value over this longer period.

In Nottinghamshire, an Accountable Care System in waiting is already gearing up to integrate the prescribing budget for musculoskeletal medicines directly into the service budget.

One obstacle has been that savings made in the community setting were of no interest to hospitals, and vice versa. But a single budget and a single pathway can take a more joined-up view to cost-saving.

“If you can make savings within a pathway, you can free up money to be spent on nurses. And if you can free up nurses, you can spend more money on drugs," says Steve.

“So, pharma has to ask itself this simple question: how do the drugs and devices we make fit into an integrated pathway on a de-siloed cost? That will be the name of the game.

“These organisations will look to you for outcomes and how you can improve them. So, the focus is shifting away from measuring activity and pills taken, and towards measuring real patient outcomes.”

He concludes by saying that long-awaited IT systems which join up primary and secondary care are now coming on stream, and enabling the vital analysis of spending and outcomes.

Paula Wilkinson on Regional Medicines Optimisation Committees (RMOCs)

Paula Wilkinson is chief pharmacist at the NHS Mid-Essex Clinical Commissioning Group, and sits on one of the four new Regional Medicines Optimisation Committees (RMOCs), introduced earlier this year.

She says the pharma industry and CCGs were both wary of the RMOCs when they were launched – one side fearing unfair rationing decisions, the other concerned they would be ordered to fund expensive new treatments. She clarified that RMOCs will make recommendations, but it is still up to CCGs through Area Prescribing Committees to make the final decision.

Paula said the RMOCs need to view new drugs and devices from the perspective of NHS commissioners as well as the clinical perspective, and highlighted the first RMOC statement.

[caption id="attachment_35437" align="alignnone" width="270"] Paula Wilkinson[/caption]

Abbott’s Freestyle Libre is a new flash glucose monitoring device for patients with diabetes. The digital devices offer a needle-free alternative to the traditional daily finger-prick and blood testing strips.

The device has been added to the primary care drug tariff, meaning GPs could prescribe it on FP10s – a concern for NHS budget holders, as spending on diabetes is already rising rapidly each year.

The RMOC recommended criteria for groups of patients who could benefit from using the device, but that it should otherwise not be routinely prescribed.

However, Paula says that the recommendation wasn’t conservative enough for many CCGs, who are considering the RMOC recommendation and tightening up the criteria.

“Everybody is looking at this and agrees it’s the right direction of travel, but it's not affordable in certain parts of the country without careful managed entry,” she said.

She concluded that managed entry systems, including proper horizon-scanning, would be necessary in the new integrated care systems.

“We need more managed entry and managed change to recognise that different CCGs are in different positions financially. As we move through to ACSs and integrated budgets, that makes absolute sense.”

She also urged the NHS to properly engage with patients on medicines, including supporting them to take responsibility for managing their own conditions.

“We need to work with patients to understand that even though the medication is free on the NHS, they still have to be responsible in the way in which they use it.

“Healthcare professionals and social workers have tried to manage patients for too long. We need to engage patients to become active partners in their care so that they get the best patient experience, because a good experience usually produces good outcomes.”

The ABPI perspective

Mike Ringe is NHS Engagement Partner (London) and Specialised Commissioning Lead, ABPI, and spent many years inside the NHS as a commissioner of services.

He says the devolution of health and social care in Greater Manchester has made the region a leader in England, and many pharma companies were actively engaged in the development of outcomes-based data systems. This work is enabling greater insights into how real world evidence can support outcomes based commissioning and contracting across NHS organisations, and potential new commercial models for medicines.

However, whilst Manchester may be leading, this approach is increasingly common across local health and care economies as the drive for integration of both commissioners and service delivery increases.

[caption id="attachment_35443" align="alignnone" width="263"] The ABPI's Mike Ringe[/caption]

Mike Ringe says there is a growing recognition across the NHS that partnership working can bring additional skills, expertise and resources into the health service, and that it's vital to transforming services. That includes the pharmaceutical industry, and he says he senses a sea change in NHS-pharma relations, with a real appetite for longer term working on both sides – not least because the health service needs all the help it can get.

“If we get it right, this leads to a triple win – for the NHS, for industry and most important of all, for patients,” he says.

He is optimistic about the ‘Devo Manc’ type developments, but highlighted some tensions in the system, particularly within specialised commissioning. NHS England remains responsible for commissioning these services, and the decision-making processes for introducing innovative medicines and treatments within its remit. So far at least, NHS England seems unlikely to give away its ‘national commissioning powers’, a budget currently worth £16.5 billion, to local systems any time soon.

“There are some interesting tensions in the system, but devolution is nevertheless very much the direction of travel,” he concluded.

It is this core goal of creating integrated care organisations over the next 5 or more years that pharma has to understand and align itself with. If it can do that, then opportunities will present themselves for cost-effective use of new medicines for the right patients.