Pharma – partners of NHS choice?
pharmafile | October 19, 2005 | Feature | |Â Â Â
The government sees choice as a major driver for promoting quality, responsiveness, efficiency and equity in public services. Choice in public sector services is gaining momentum: it was a key issue in the the last election, and having released its response to the Public Administration Select Committee's (PASC) report on Choice, Voice and Public Services (18th July 2005), the government has again made it clear that choice will be a major element of public services in the future.
Choice of hospital provider has been on the horizon for quite some time (launched in the Department of Health's Building on the Best: Choice, Responsiveness and Equity in the NHS in December 2003). Choice has also been trialled through pilot schemes offering faster treatment to those who have been waiting for six months or more.
These have, in general, been seen as successful, with large numbers of patients willing to exercise their choice (although this is partially down to a reaction to long waits with their nearest provider). Choice in healthcare is ramping up with the implementation of limited choice of hospital provider at GP referral in December this year.
The hope is that if people can choose where to be treated services will need to respond more effectively to patients' demands. Hospitals will no longer be able to offer cut-price operations to entice PCTs to send patients their way under Payment by Results (PbR) – a fixed price per episode financing system.
Choice of hospital provider has therefore provided a new emphasis on the potential impact on traditional ways of working in the secondary sector. What about the role of choice in the primary care sector?
Scope of choice
The scope of choice in primary care is still being worked on by the Department of Health, but there are a number of ways that choice in primary care could be put into operation:
- Could patients choose where their primary care is delivered? At home, on the back of a mobile health centre, or near their workplace?
- Could patients decide who delivers their care? The local GP, practice nurse, or even a specialist service provided by a separate independent organisation?
- Patients may also be able to choose the time when care is delivered, in line with the secondary care Choose and Book venture where patients will, eventually, be able to see a list of potential slots and choose those which are most convenient to them.
- More contentious patients could (within reasonable limits) be able to decide what type of treatment they want.
This highlights the potential range and scope of choice in primary care, with the latter likely to have an impact on pharma. For example, allowing patients choice over where and what treatment they have could help to counter some of the financial incentives under PbR.
One example raised by a pharma company is the out-patient-based infusion of one of their key products which is strongly incentivised by the PbR framework. This could override the patient preference for the at-home oral-based version of the product. Choice could mean that patients are the driving force for the location of their care.
Early signs from the DH are that choice in primary care could be quite radical. For example, Julian Le Grand (previously health advisor to Tony Blair) has talked about independent providers providing chronic care in competition with the NHS and even mentioned the possibility of letting patients commission chronic care themselves. It seems likely that choice in primary care will include chronic diseases and tie in neatly with chronic disease management.
Opportunities for pharma
The Choice in primary care agenda gives extra focus to the already present drivers for collaborative working with primary care trusts and community pharmacists and could very well mean a brand new set of agencies with which to begin relationship building.
It could also place even greater emphasis on alternatives to the traditional delivery of primary care, especially chronic care (if Julian Le Grand's hints indicate the way the Department is thinking). The pharma industry is one partner to consider when designing and delivering new options for patients.
There are already good examples of major pharma companies working alongside PCTs. The Pfizer Haringey PCT collaboration, set up in February 2004, is seen as a major step forward in building a successful partnership between the NHS and the pharmaceutical industry. The scheme is focused on a chronic disease management programme including a telephone, IT system and health coaches that provide support, motivation and encouragement for patients to play a more active role in the management of their condition.
The programme covers a range of chronic illnesses including coronary heart disease, congestive heart failure and diabetes. The scheme is small, covering some 600 patients, but offers an opportunity for the industry to demonstrate the skills that it can bring to a PCT. An independent evaluation of the scheme is due to report later in 2005, but it is anticipated the PCT will benefit from enhanced management of their chronically ill patients which could also feed into better outcomes for patients.
Chronic disease management is not the only way that companies have worked with PCTs. Lilly has been involved in a partnership with the London Development Centre to contribute to understanding the skills, expertise and training required for commissioning mental health services.
This has delivered direct benefit to local commissioners through the development of a training programme and will also feed into better services for patients. In a similar scheme Wyeth was able to provide training to new Primary Care Link Workers, who are working with local health services to build better mental health care for Norwich PCT.
The industry has also played a role in screening: Abbott Laboratories has been working with Gloucestershire PCT to screen older people for nutritional deficiencies. This will help identify those at risk and then put in place the appropriate treatment strategies.
The scheme showed clear benefits to patients by tackling poor nutrition and combating ill health linked to poor nutrition. This helped the PCT make better use of their dietician by cutting the number of inappropriate referrals – for Abbott it enabled them to raise their profile within the PCT.
Pharmacy collaboration
Community pharmacists are playing an even bigger role in primary care, reflecting the major changes to their contract with the DH. A key change has been moving the focus away from dispensing fees and increasing emphasis on payment for other services. This recognises the wider role of today's community pharmacists in primary care, a role encompassing screening and playing a part in managing chronic disease through the best use of medicines.
There are also good examples of industry collaboration. Roche has been providing diagnostic screening packs to some local pharmacies as part of Local Pharmaceutical Services contracts. It is also working with a number of PCTs to develop a community pharmacy based diabetes screening programme.
These types of partnership link well into the development of super surgeries, which will combine a whole host of healthcare providers (from the GP, physiotherapist, dentist through to community pharmacy) in one place.
The independent sector
Choice in primary care could be a key driver for the introduction of a new set of players in primary care. The DH has shown a willingness to embrace the independent sector as a lever to change in the wider NHS and there are early signs that the independent sector could also be allowed to be a player in the choice driven primary care sector.
There are relatively few primary care specialist independent sector providers currently in the UK but there's a whole host of companies that could diversify or enter the UK. These include current UK hospital providers, overseas hospital providers and primary care specialists, or domestic and international providers of diagnostic services.
The potential for partnering with these new players is no different to the existing PCTs and community pharmacists. The industry could partner in providing nurse expertise, medicine audit, screening, etc, as before, but pharmaceutical companies could gain by acting first and getting in place the right relationship from the outset.
It is possible that the industry may become one of the new providers in the primary care choice market, whether this is through a consortium or as a stand-alone provider. At this stage it is difficult to anticipate what form choice in primary care might take but if the DH is thinking radically then this could be extended to the type of outcome-based scheme used by Pfizer in Florida in the US.
In that scheme Pfizer struck a deal with the Florida Medicaid system to provide disease management and significant savings in return for its products being included on the Medicaid formulary. The scheme focused on 12,000 patients who had chronic diseases such as diabetes, asthma, or heart disease.
Around 60 nurse case managers using IT support provided encouragement to patients to manage their condition, including attending clinics for regular check-ups. The scheme was renewed in 2003 and estimated savings were in the region of $16 million from December 2001 to June 2002.
While some companies have already been active in collaborating with with PCTs and pharmacists, other big names have yet to follow suit. The opening up of primary care to choice could increase this collaborative approach, only this time with new independent providers.
Choice in elective surgery was partly facilitated by independent sector treatment centres – a plan driven through centrally by the DH. It is unclear whether this route will be appropriate for primary care choice but interested companies should be thinking strategically and may wish to prepare for the possibility of centrally driven procurement.
