NHS 2008: Rejuvenating the 60 year-old service

A review of the NHS in 2008

NHS-pharma collaborations come of age

In January, new guidelines were agreed to help NHS bodies work with the pharmaceutical industry and, after months of negotiation, they offered the opportunity for closer ties.

The agreement will give PCTs and other health service bodies a more detailed and formal set of guidelines about how to engage with pharmaceutical companies.

A selection of the best examples of pharma-NHS collaboration were highlighted in the new guidance, including a project conducted by East Lincolnshire PCT in alliance with three pharma companies on chronic obstructive pulmonary disease (COPD).

The project identified people with suspected COPD and provided training for clinicians to manage these patients and establish specific COPD clinics. The programme saw a 23% reduction in admission rates in COPD, compared to a single figure fall in neighbouring PCTs. Over a five-month period, 78 out of 215 case-managed patients had acute episodes that were managed at home with only one resulting in hospital admission.

Health minister Dawn Primarolo said this fitted with patient expectation to have their care provided in the community.

“We know that joint working between the NHS and pharmaceutical industry can bring real benefits to patients so we want the NHS to work with them more to improve patient care,” she said. “This best practice guidance demonstrates that patients really can get better care when the NHS and industry work together.”

Judith Smith, respiratory nurse consultant, and Noel Kelly, a GP with a specialist interest (GPwSI) in respiratory medicine, from East Lincolnshire PCT said: “This guidance will help steer NHS organisations in developing transparent mature relationships with the pharmaceutical industry. “Ultimately both the NHS and industry have a common shared goal in improving patient well being with effective treatments and services.”

Richard Barker, director general of ABPI, said: “The pharmaceutical industry has a huge amount of expertise, not only in the modern, innovative medicines it has researched but also in the conditions they have been developed to treat.

“Increasingly, the importance of this knowledge being shared with our partners in the NHS for the benefit of patients is being recognised, and this guidance can only encourage the constructive use of such activity in the UK.”

The best practice guidance and the Ministerial Industry Strategy Group’s long-term leadership strategy report, with supporting studies, can be found online at the Department of Health’s website.

Box: Collaborating on COPD

In June a group of pharmaceutical companies joined forces with Nottingham healthcare services to help improve care for patients with chronic obstructive pulmonary disorder (COPD) and reduce unplanned hospital admissions.

INFORCE (Industry and Nottingham NHS Focus on Reducing COPD Exacerbations) is a collaboration between Nottingham City PCT, Nottingham University Hospitals NHS Trust and five pharma companies with an interest in COPD.

The companies taking part in the programme are GlaxoSmithKline, AstraZeneca, Boehringer Ingelheim, Pfizer and Nycomed.

In Nottingham’s most deprived areas death rates from the lung disease, which is usually caused by smoking, are over six times higher than in affluent areas.

Hospital admissions in these areas are also five times higher, and around 140 people die of COPD-related illness in Nottingham every year. There are up to 1,000 hospital admissions each year, many of which are multiple admissions of the same patients.

The project will run for two years until December 2009 and will have four phases. Patients with COPD will be invited to take part and their treatment will be analysed by looking at medical records and through direct discussions with patients.

The data gathered will then be reviewed to identify common factors that may lead to hospitalisation, with a view to improving care and preventing patients deteriorating.

INFORCE was set up as part of the ABPI Outreach Programme to encourage the NHS and pharma to work together to improve patient care and achieve NHS targets.

The programme is part of the government’s wider ‘Working Together’ initiative to develop better joint working between the industry and the NHS.

BMA and minister trade blows in echoes of 1948

The government had prepared itself for the 60th anniversary of the creation of the NHS in July this year.

To mark the occasion, Lord Ara Darzi’s NHS Next Stage Review was meant to reinforce the health service’s public remit, with a new commitment to patient care and autonomy from political interference. But the row over polyclinics provided an uncanny reminder of the NHS’ birth pangs.

Polyclinics were planned to be launched across England in Darzi’s preliminary NHS Next Stage Review, and promised to improve care by bringing the services of an area together to a single patient facility.

The plans centred around the creation of 150 new centres which would pool resources and create new ‘super surgeries’ in the community with the aim of improving patient choice, cutting hospital admissions and saving money.

But the BMA, backed by the Conservatives said that 1,700 GP surgeries would have to close as a result of being forced into the super surgeries.

Dr Laurence Buckman, chairman of the BMA’s GPs committee, said: “Although large health centres may work in some areas where patients and clinicians agree on a proven need, the government wishes to impose the polyclinic model on every PCT in the country regardless of need or demand. Private commercial companies would also be able to bid for the new centres leading to fears that they will be more interested in their shareholders than patients.”

Alan Johnson hit back, calling the campaign “one of the most disingenuous” he had ever seen, and said the BMA had deliberately tried to mislead the public over what the government plans actually entailed.

The gloves came off when he used a speech to remind everyone that the BMA and the Conservatives had bitterly opposed the setting up of the NHS itself in 1948.

“The ludicrous misrepresentation of this policy by the BMA and the Conservative Party is a faint echo of their infamous double act 60 years ago when they opposed the creation of the NHS itself,” he said in June.

But then the respected King’s Fund weighed into the argument, with a report saying there was no evidence to show it will improve patient care.

The timing of the King’s Fund report was an embarrassment for the government, coming just days ahead of the Next Stage review.

Chief executive of the King’s Fund Niall Dickson urged ministers not to make the polyclinic model compulsory. “Polyclinics may be the right answer in some areas, they will not be right for others. That should be a matter to be decided locally on a case-by-case basis using the best clinical evidence available together with a full assessment of the costs and the impact on patient access.”

It researched the current and limited development of polyclinics both in the UK and abroad to give key findings on cost, accessibility of services and quality of care.

It found that while polyclinics could bring some benefit to some patients, there was no real evidence that they would universally improve quality of care and accessibility of services and that there is no proof that larger GP practices deliver higher quality care than smaller ones.

The opposition has seen the government back down from forcing areas to adopt the full ‘polyclinic model’, although plans remain for each PCT to see a new centre open in 2009 or 2010. In most cases, these will be a watered down ‘GP-led healthcare centre’ concept in the regions, with only London retaining the polyclinic plans.

The government took care to back down from to close A&E and other departments at hospitals around the country, as this had seen large-scale local protests around the country, although this kind of tough disinvestment may be necessary to make its primary care reforms a success.

Practice Based Commissioning – still falling short

Practice based commissioning isn’t working and requires a major overhaul, according to a report by think tank The King’s Fund published in November.

The two year study of Practice¿based commissioning (PBC) said the theory behind the policy – to devolve greater power to GPs – is sound, but that it has failed to make a significant impact.

Practice-based commissioning: reinvigorate, replace or abandon? says the government was right to recently re-commit itself to PBC, but concludes that so far it has produced few benefits for patients or NHS finances since its launch in 2005.

Report co-author Nick Goodwin, senior fellow at The King’s Fund, said: “Practice-based commissioning has the potential to deliver better services for patients and financial savings for the NHS, but progress has been painfully slow over the past three years.

“As a policy established to pump-prime the transition of care out of hospitals by investing in alternative care in local communities, it has so far failed due to a lack of real investment, leadership, ambition and drive.”

Goodwin says the government must make the most of dwindling GP enthusiasm and commit to a fundamental redesign of the policy.

The study found very few of England’s GPs use the system to commission new services, despite having been paid almost £100 million in incentive payments alone. The report says the policy needs a major overhaul, and lack of interest from GPs must be tackled if it is to be a success.

It concludes many barriers to progress should have been predicted given the experience of the similar ‘fundholding’ system used by the Conservative government in the 1990s.

Engaging GPs is one of the biggest problems, and the think tank says GPs will be more enthusiastic if they are given more freedom. It recommends allowing them to contract independently by giving them real budgets for specific therapeutic areas.

Another key issue is lack of managerial capacity, with a new breed of administrators not currently in place. The report says the right skills, data systems and governance arrangements all need to be in place for the system to work properly.

Niall Dickson, chief executive at The King’s Fund, added: “The government is right to keep faith with practice-based commissioning but it must be prepared to set a clear direction, define the commissioning roles of both PCTs and practices, ensure GPs have access to the support they need to make it work and put in place the correct incentives. Now is the time for a fundamental reassessment of the policy.”

GPs reported that they had limited time to engage in the policy, and often lacked the necessary skills and data, and generally lacked support from PCTs.

Concerns over conflicts of interest in the role of GPs as both providers and commissioners of services, was also a barrier, potentially restricting patient choice.

‘Don’t blame the PCTs’

The NHS Alliance represents many of England’s GPs and other primary care workers and says the Kings Fund report is an accurate reflection of the problems.

But NHS Alliance chairman Dr Michael Dixon says the blame should not lie with PCTs but rather with the health service hierarchy.

“There should be no excuse for failing to provide budgets and accurate financial information to practice based commissioners. Yet that is exactly what has been happening. It is often not the fault of PCTs but of the system above them.”

One particular problem Dr Dixon points out is the lack of timely and accurate data supplied by acute trusts, which GPs rely on in order to use practice-based commissioning.

“The King’s Fund is right to say that urgent action is necessary to overhaul PBC. But that action need not be complex or costly. The simple solution we have proposed would transform commissioning by putting the power where it should lie ¿ with the commissioners instead of, as at present, with the acute sector.

“If providers find they do not get paid unless they do the job properly, that would sharpen everyone’s performance. And it would also enable practices and PCT commissioners to become fully engaged in NHS decision making.”

King’s Fund recommendations:

* The government must provide a clear vision for PBC and provide national guidance for GPs and PCTs on how to implement the policy locally

* PCTs should maintain responsibility for strategic commissioning but be informed by GPs and other clinicians, while real budgets for specific services should be devolved to GPs and PBC ‘clusters’, giving them more freedom and stronger incentives to develop better services for patients

* High performing GPs and PBC groups should be rewarded with more independence but should not become responsible for the entire health care budget. Budgets should only be devolved for tightly defined areas so GPs can only commission specific services directly, which would reduce clinical and financial risks

* Conflicts of interest in the role of GPs should be formally addressed to ensure patient choice and the quality of GP referrals are not compromised and that clinical risk is managed.

Government signs up supermarkets to help tackle obesity

A ‘lifestyle revolution’ planned in new public health initiative

More exercise and healthier eating are at the core of the government’s new anti-obesity initiative, called Change4Life.

Billed in November as a “lifestyle revolution”, one of its main ideas is to harness the power of supermarkets in determining what we eat.

It follows on from 2007’s Foresight Report, which concluded that overweight or obese people cost the economy £7 billion in treatment, benefits, loss of earnings and reduced productivity.

Without action, costs by 2050 would be £50 billion – or almost half the NHS’s current annual budget.

“Obesity is the biggest public health challenge the country faces,” said health secretary Alan Johnson. “If we don’t take action now we will condemn our children to reduced life expectancy.”

Around 90% of today’s children will otherwise be overweight and at risk from serious diseases in 30 years’ time, he believes.

Parental ignorance of the link between obesity and conditions such as heart disease and cancer – as well as lack of confidence about cooking from scratch – are key factors in the problem, says Johnson.

Department of Health research suggest that parents don’t recognise their children are overweight and underestimate how much unhealthy food and convenience food they buy.

They also overestimate the amount of activity their children do.

“Finger wagging and lecturing won’t work, that’s why Change4Life is designed to be supportive and helpful,” he concluded.

From January, Tesco will run themed Change4Life promotional activity in store on healthier products under the banner Change4Life 4 Less.

Meanwhile Asda will run promotions that encourage healthier eating and support cycling as a family activity.

“Ten million people visit their corner shops every day and 36 million shop at Asda and Tesco each week – the fact that grocers and supermarkets are on board means we can really influence what goes into our shopping trolleys,” said Johnson.

In addition to supermarkets, the government wants support from other companies and charities.

It says that so far 12,400 organisations including Cancer Research, Diabetes UK and the British Heart Foundation, PepsiCo, Kellogg’s, ITV, the Association of Convenience Stores and the Fitness Industry Association have signed up.

Next year ITV1 will track viewers’ progress in meeting personal pledges to lead healthier lives.

Kellogg’s is to invest £100,000 a year for the next three years to create breakfast clubs in the 500 most deprived areas in Britain, and provide access to all children in the UK by 2013.

PepsiCo is to fund advertising to promote the benefits of active play, featuring some of its contracted sports stars. The government is also talking to BSkyB, Kraft and Unilever.

Now wash your hands – the battle against the superbugs goes on

One of the most high profile NHS stories in 2008 was the battle against superbugs.

Potentially fatal healthcare associated infections have been a major focus for media concern in recent years. In January millions of pounds in extra funding was announced for hospitals in England to appoint a team of nurses and pharmacists to help control the spread of superbugs.

England has one of the worst rates of superbug, or healthcare associated infections in Europe and the government has made tackling the problem a top priority.

The extra funding is part of the Department of Health’s ‘Clean, safe care’ initiative which brings together current HCAI initiatives and details new areas where the extra funding of £270 million per year by 2010/11 should be spent.

Up to £45 million of the total was earmarked on hiring additional specialist staff to ensure cleanliness and infection prevention and control, with two infection control nurses, two isolation nurses and an antimicrobial pharmacist recommended in every hospital.

The remainder of the funds is to be spent on implementing the raft of other measures the government has introduced, including screening for all elective patients by March 2009 and a deep clean in every hospital trust by March this year.

Health secretary Alan Johnson was able to point to some success in tackling MRSA , but infections caused by C. difficile now pose a greater threat. Johnson said:

“We have gone from what has been described by the HPA as ‘a seemingly unstoppable rise in MRSA bloodstream infections throughout the 1990s’ to a 10% fall in cases of MRSA, thanks to the hard work and dedication of NHS staff, but we know that there is still more to be done.”

There are two key targets for NHS trusts to hit by 2011 – cutting MRSA bloodstream infections to less than half the number in 2003/04 and reducing the number of C. difficile infections from 2007/08 numbers.

In November, a review by watchdog the Healthcare Commission of 51 acute trusts found just over half failed to keep all areas clean and well-maintained.

However, it said most had improved in relation to leadership and ensuring uniforms were clean and fit for purpose.

Chief executive Anna Walker said it was clear that the NHS was paying close attention to infection prevention and control, and had made real progress with many getting good systems in place and demonstrating clear board leadership on this important issue.

“Where we have raised concerns, we have generally been encouraged by the positive and prompt response at those trusts.

“Importantly, we have found few breaches requiring immediate action to protect the safety of patients – and where we have we have taken swift action.”