The NHS in 2013: a review of 2012 and a look at the year ahead

Anthony Rowbottom

Clinical Current

Anthony Rowbottom starts his new series looking at changes in the NHS as they develop. This first piece explores the NHS environment throughout 2012 and looks ahead to this new year.

As we start the New Year, it seems like a good opportunity to reflect upon 2012 and look forward to what 2013 will hold. The NHS reforms have proposed, and will deliver, significant changes to healthcare provision in England, effective from April 2013. Not least among these changes is the fact that all Primary Care Trusts in England will be replaced by new Clinical Commissioning Groups.

This article is the first installment in a series of updates as we look ahead to when the Health and Social Care Act 2012 transforms the healthcare landscape from April 2013 onwards. It’s our intention to specifically focus on CCGs in later articles but for now, here is a simple and concise roundup of the reforms.

What is actually changing?

It is true to say that in terms of organisational structure there will be significant change to the NHS in England. However, if we consider visible service provision and how patients experience the NHS then the changes won’t appear to be quite as profound at least for the time being.

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“The NHS reforms have proposed, and will deliver, significant changes to healthcare provision in England, effective from April 2013.”

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The philosophical underpinnings of the reform stress a greater role for local decision making and transparency as well as the (controversial) inclusion of regulations allowing private healthcare provision through ‘Any Qualified Provider’ (AQP). On top of which, a continued emphasis on treatment outcomes will mean a more performance-focused environment for pharmaceutical companies to operate within.

Local healthcare for local people

For a long time, certainly since the creation of PCTs in 2002 and the Wanless report in 2004, the NHS has been on a drive to become more local. This enthusiasm for local decision making is driven largely by a desire to emulate Local Authority success in driving up quality whilst cutting costs in parallel.

Whilst some (such as the NHS and Healthcare commentator Roy Lilley) have already hailed attempts at innovation &amp, quality improvement through the QIPP initiative as dead, it’s principles of quality, innovation and transformation of the UK’s healthcare system live on. No more so than in a desire to involve patients, (the very reason healthcare exists at all) in commission decision making. Whilst patients will have direct representation in the commissioning process, it remains to be seen how much influence they will actually have. Through HealthWatch, which replaces the old patient involvement network LINk, and the Health &amp, Wellbeing Boards, which are designed to facilitate interaction between an individual CCG and the Local Authority, patients should be well placed to influence decisions. However, a report by the King’s Fund in 2011 highlighted that when commissioning locally, in conjunction with patient representation, patient influence actually becomes marginalised:

? cross-CCG relationships were slow to develop and CCGs struggled to manage their constituent practices (lack of local coordination).

? the role of the National Commissioning Board expanded rapidly (looking to national leadership).

? public health and the patient voice were largely ignored as the health and wellbeing board and HealthWatch became marginalised.

So is local decision making with patients merely a facade? Will CCGs merely be re-branded PCTs?

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“So is local decision making with patients merely a facade? Will CCGs merely be re-branded PCTs?”

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Anything you can do, I can do better

The most controversial part of the reform however, and the part that received most media attention, is the apparent outsourcing of parts of the NHS to private sector contractors. This is something which a lot of people fear will lead to the long term dissolution of the NHS as we know it and a system whereby only the rich can afford adequate healthcare. Whilst this system of AQP certainly does open the NHS door to the private sector, the level of care provided needs to be at least as good as the care provided to patients by NHS services (it will be written into their contracts) and if managed properly should lead to the improved quality of healthcare, for the rich and the less well off.

AQP is considered to be cost saving in the long run: current services will be streamlined and made more efficient, benefitting all by opening them up to private company competition. Some have voiced concerns that the most profitable services will be ‘cherry picked’ by private providers, leaving the most costly services in the hands of state run organisations – essentially costing the taxpayer more money. Even if so called ‘cherry picked’ services are taken away, however, it frees up resources to be reallocated elsewhere if the payments process is properly regulated (which will be an organisation called Monitor’s role).

At the moment, AQP is not in widespread use however some initial steps in that direction are already underway – some audiology services have been opened up to private providers with some success. No doubt more will become clearer closer to April 2013.

The drugs don’t work

The article An Outcomes Focused NHS recently explored the increasing role and focus on outcomes by the NHS. This will become an increasingly important consideration as the health reforms are implemented and will see a drive by the NHS to understand which treatments are currently most / least effective in a given patient population.

The powers and responsibilities of NICE have, as a result, been considerably expanded by transforming the organisation into a non-departmental public body. These duties also include an expansion of patient treatment pathways, an evidence based approach at looking at individual diseases and the drugs used to treat them in order to understand which are best used at what stage of a disease. In future, the role of NICE will expand to also cover the social care sector.

Perhaps the greatest impact upon the pharmaceutical industry however, will be the development of the Commissioning Outcomes Framework (COF) by NICE in conjunction with the NHS Commission Board. The COF:

“will allow the NHS Commissioning Board to identify the contribution of clinical commissioning groups to achieving the priorities for health improvement in the NHS Outcomes Framework, while also being accountable to patients and local communities. It will also enable the commissioning groups to benchmark their performance and identify priorities for improvement.”

This also impacts on how current and future treatments will be perceived, meaning objective population-wide improvements need to be documented and made public (at least to NICE) – which ties in with ‘An Outcomes Focused NHS’ as mentioned earlier. Current COF strands include, but will not be limited to: Cardiovascular, Gastrointestinal, Respiratory, Mental, Endocrine, Nutritional, Metabolic, Maternity, Reproductive, Oncology issues.

So the question remains: will the treatments we currently use and market in the UK live up to these standards and how will the treatment landscape change over the next few years as a result of the reforms? The current landscape only encourages drug manufacturers to pass a minimum hurdle (better than a placebo when treating). Focussing on outcomes changes this balance, meaning manufacturers will have to consider post-launch data and seek to prove a drug’s effectiveness and safety in real world patient populations.

April 2013 and beyond

As part of this ongoing series, we’ll aim to answer some of the key outstanding issues and questions, as well as give you an overview of the stages of CCG approval come April 2013.

Current status of CCGs in the approval process

There are currently 211 CCGs across England, with the first of three Phases of Approvals happening right now. 35 CCGs have been placed in Wave I approval – which means details of their approval status will become public in early December 2012. In total, there are 119 individual organisational and process aspects a CCG needs to pass before it successfully becomes a functioning CCG, which are all examined by the NHS Commissioning Board.

The next article in this series will be published in early February.

About the author:

Anthony is Head of Health &amp, Engagement at Clinical Current, a specialist health consultancy and technology business based in London.

Anthony joined Clinical Current at an early stage and helped launch the community, having a long history in healthcare: starting his working life at a small healthcare market research agency in Oxfordshire, then moving to London and finally joining Insight Research Group. Anthony has worked with numerous blue-chip pharmaceutical companies over the years and has previously been involved in successfully launching healthcare professional technology platforms.

Anthony is a keen cyclist and Germanophile – combining both, he is aiming to cycle from London to Berlin in 2013 and further afield in the near future. Anthony is also a lover of politics, both domestic and international … check out his Twitter feed in &amp, around BBC Question Time for some interesting debates!

How will the treatment landscape change as a result of the NHS reforms?