A clinically-led NHS: a new opportunity to improve health

pharmafile | March 13, 2013 | Feature | Manufacturing and Production, Medical Communications, Research and Development, Sales and Marketing |  CCG, NHS, Portmsouth, hogan, pharmafile 

Dr Jim Hogan was speaking at the Prescriber and Pharmafocus conference: CCGs, the new NHS and Pharma in December.

First of all, let me tell you about our area – Portsmouth is an exceptional place in many ways. It has been called ‘a northern town on the south coast’ because of the high levels of urban deprivation. Our population is 207,000 and one in four children in the city lives in poverty, and 16% of children grow up in a household where they have no wage earner.

Our elderly population is already at the level the rest of the UK expects to have in 2030, and we are the most densely populated place in Europe outside London. We also hold the record for the number of times our football club has gone into administration – that really affects the mental health of some of our male population! So lots of challenges there in improving the health of our population.

The authorisation process

Our CCG has been blessed and cursed by being in the first wave to be authorised; blessed because we could get out and get through it quicker, but cursed because, as always with the NHS, you get a feeling that they make it up as they go along. The process has been around turning 119 red lights green – the DoH counted 118 and we counted 119, and unfortunately we were right.

We were approved by the NHS Commissioning Board’s authorisation committee with one condition, though I think that condition was more of a political statement than anything to do with our performance, really.

Going through all of these processes, it has been quite hard to be different from what has gone before – the system wants to repeat the same mistakes it has made in the past. And the bureaucracy that we are trying to dismantle, there is a danger that in some areas we are just recreating that. In Portsmouth we have dug our heels in order to do something new.

We also have additional challenges – our acute and community trusts are going through the Foundation Trust pipeline – one more successful than the other. We have a huge PFI hospital that we have to feed. But we are also co-terminus with our local authority, which is a huge advantage.

Why we are different to PCTs

As clinicians, we didn’t choose the job of being CCG leaders, we were asked to take it on. We have been chosen because of our proximity to patients and the public.       In terms of the name ‘Clinical Commissioning Groups’ – for once I think the label is appropriate.

In contrast, Primary Care Trusts didn’t have a lot to do with primary care, really, but CCGs do what it says on the tin. In Portsmouth we have gone for the total clinical leadership – so a clinical chair (Dr Tim Wilkinson) and a clinical accountable officer, which is my role. I think that is what was intended in the reforms when they started, but unfortunately across England there are only 40 out of the 211 CCGs which actually have a clinician as the accountable officer.

This is what our membership wanted – this is what we are about – true clinically led commissioning. I think one of the challenges we have is to rebuilt public confidence in services that we have, because I think that confidence is waning. The relationships between primary and secondary care have also suffered in the previous system, so we need to rebuild those as well.

There is a lot of rhetoric about the need for integration of services in the NHS, but I also think there is work to be done through collaboration, and that is in delivery of services as well as planning services. The other important goal for Portsmouth CCG is to align incentives across all sectors and all levels – if we aren’t all pushing in the same direction, we are never going to get anywhere.

We have got 211 CCGs nationally, David Nicholson has said he couldn’t afford 250 PCTs, I think he can’t afford 211 CCGs. So the way in which we work collaboratively is going to be very important. We have a good working relationship with our two sister CCGs [Fareham and Gosport CCG and South Eastern Hampshire CCG ] so we try to work as a single health economy.

CCGs will be responsible for 80% of the commissioning budget, for Portsmouth that is going to be £270 million. Let me make it clear that the CCG is not a provider of services – there has been a lot of talk about conflicts of interest, but we are here purely as clinical commissioners. The remaining 20% of the budget will go to the National Commissioning Board, and our Local Area Team (LAT) representing the board is now in place.

Ours will be across Hampshire and Dorset, so really that is a not-that-local area team! LATs are going to be a very lean organisations, and our LAT colleagues are saying they won’t be able to cope with overseeing specialist services and primary care, so they are pushing that back to CCGs. So I think the way in for the pharmaceutical industry will be through CCGs, who will also want to be influencing their LATs over such things as vascular services and High Cost Drug spending.

Another break with the past is that CCGs are very close to their members  – don’t think CCGs are these remote boards. CCGs are built around the membership practices, and in Portsmouth we have 26 practices, which have list sizes that vary from 3,000 to 30,000.

Regarding our NHS Acorn Award, one of the main reasons we were awarded that was because of the way in which we are trying to involve the membership as we move forward. We have come up with a few innovative tools – one is a primary care information portal, everything is in one place.

We have also developed a dashboard benchmarking tool called Delivering Outcomes in Clinical Care. We have found this actually does support practice engagement, and helps us performance manage primary care at the same time. I guess we are also different in Portsmouth because we have an area prescribing committee that works across a single health economy, it has representation from primary and secondary care, and has real control over both primary and secondary care.

New ways of working

I think we in primary care have been very used to the pharmaceutical industry sitting outside our door and then climbing through the window to escape! Using stealth in approaching the NHS, and regarding services in a fragmented way is not the best way to introduce drugs to primary care. I think the future with pharma is integration and better collaboration – you just have to consider that about 60% of what we do involves drugs as an intervention.

As we move towards Value-Based Pricing and payments based on outcomes, we are going to need to work together. I think one of the things that is going to help us take that forward is this concept of ‘Health and Wealth’ as set out in the government’s Innovation, Health and Wealth report.

I think we have finished with the Medicines Management concept – we have swapped drugs and we have got our disease registers all sorted. I think we now see medicines optimisation as the way forward. At the moment, when a new drug comes out, our secondary care colleagues get excited by it, while medicines management in the PCT are trying to destroy literature, and keep a lid on it! In some cases we have seen use of new drugs linked to poor performance, which is sad.

I think we lose real opportunities to improve outcomes for patients. I think we are all looking to improve our own reputation and those of our partners – primary care, secondary care, social care and the pharmaceutical industry. From my perspective, I really want to be seen as a credible commissioner, so I want to make better use of resources and reduce hospital admissions.

In order to do that, we need to be more creative in the way we do things. We need to ensure we have equitable and consistent access to services. We need better outcomes, and that means more people being given the appropriate treatment. Another component is the need to creater clearer pathways for patients.

Pathways are very clear when you are a clinician, but if you see them from a patient’s perspective, they are a lot less comprenhensible. Alongside that, we are trying to move forward with a concept of standardisation of care as well, especially in primary care.

Challenges

The financial environment in the NHS is very difficult now, and it is more difficult to be innovative now that the growth in budgets has stopped. We are having to disinvest to invest, we are having to save to spend. Our QIPP challenge is £5million, year-on-year for the next three years.

Meanwhile, we also have hospitals who have to do their own improvement programmes, so there is a danger that our QIPPs overlap with their SIPs [Service Improvement Plan]. That means we are in danger of doing a lot of double counting when identifying savings, so we are sitting down to plan together rather than do them in silos.

I think it is very difficult when you have perverse incentives and misaligned incentives – Payment By Results [for acute trusts] and QOFF [for primary care] don’t match.

One thing we did in 2012 was to try to force collaboration and integration between our acute and community providers by using the CQUIN (Commissioning for Quality and Innovation) payment as a tool to do that. They have a joint target, and if one of them doesn’t hit the target, none of them get the payment. It is amazing how quickly that has changed behaviour.

CCGs and pharma collaborations

So where are the opportunities for CCGs and pharma to work together? Well, much of it is obvious. I put partnerships at the top of the list, because there are real gains to be had from pharma working with commissioners.

I really think we need to move towards planned and targeted use of new drugs. There needs to be some Cost Impact Analysis work done when new products come out, because we need to know what it is going to save us when these new drugs come out. 

That would make us more willing to be proactive. We have seen some real opportunities missed in the past, especially with drugs in diabetes, where you have only got a limited time to treat these patients before it is too late. 

We are currently doing some work around the new long-acting insulins that are coming out, and the opportunities for us to save from reduced hypoglycaemia admissions. So you have to ask yourselves, what is in it for you, and what is in it for us?

We talk a lot of pathways in the NHS, but I think the health service still develops pathways in silos, and there are a lot of pathways with gaps in them. I think pharma could play a role in smoothing some of that out.

Another area where there is a lot of work to be done is in medicines optimisation. Portsmouth PCT worked with the Hampshire and Isle of Wight local pharmaceutical committee (LPC) to set up the Healthy Living Pharmacy programme a few years ago.

This has given community pharmacies a role in delivering health and wellbeing services, and providing proactive health advice and interventions, such as smoking cessation. This model has been a big success, but I think we could also get pharma to help co-ordinate support for medicines optimisation.

That is not just about education, but about enabling patients to make real choices about the care and treatments they get. There is also a huge agenda around promoting self care and enablement for long- term conditions.

Then there is the issue of non-medical prescribers. They need support, and we need to ensure that the correct drugs are used, and used in the correct way, so there is a role for the industry there.

In QIPP, we often forget about the second ‘P’ which is Prevention, and there is a lot of work we need to do on this. We do a lot of work on Quality and Innovation, but there is something missing on Prevention. And from a perspective of professional education, we need to standardise care by standardising education, and we are already working with pharma in Portsmouth to try to assist that.

A tale of two vascular endothelial growth factor inhibitors

Portsmouth is the birthplace of Charles Dickens, so I’ve chosen to refer to this as A Tale of Two Vascular Endothelial Growth Factor Inhibitors. Don’t worry, I won’t mention any names! I am not going to pass judgement on this, either, I will simply explain the process we went through. Portsmouth has a QIPP pressure of £5 million – so that is a sum that we must save, and then reinvest in services.

We looked at the two drugs that were both being used to treat wet age-related macular degeneration. Both had been through clinical trials, but one hadn’t enough clinical trials to give it a licence, while the other which had the licence costs 12 times as much. So for Portsmouth, the potential for cost savings were £4-5 million – when you take that nationally, that’s a potential to save £85 million.

And all of this money would be reinvested in the whole population outcome. We in Portsmouth have a Clinical Leaders Group, which brings together the leaders from primary care and acute provider trusts.

We also have a sustainability programme, because we have a gap in the local health economy of £250 million. We identified the VEGF drugs as an opportunity, it was supported by a priorities committee locally, we commissioned an independent report on public health from Solutions for Public Health, and we produced a policy statement supporting the use of the cheaper drug… and then we had the decision challenged with a judicial review [by the pharma company].

We eventually agreed a deal with the company on the price of the licensed drug, so the PCT was able to revoke its policy statement, and that settled the matter. But it does bring up a lot of issues, beyond the obvious ones about using licensed versus unlicensed medicines, and prescribing off-label.

One question is – where is NICE when you need them? We get a lot of guidance that we’d rather not have, but they weren’t there when we really needed them. And where are the GMC in all of this? Their advice is often conflicting across professions.

So to conclude, I would say simply – we need to focus on outcomes, not incomes. We all exist in a complex system, but unless the NHS and pharma start to work together and align incentives, we are not going to be pushing in the same direction and we won’t achieve anything.

Dr Jim Hogan was speaking at the Prescriber and Pharmafocus conference: CCGs, the new NHS and Pharma in December.