Saving billions through ‘innovation’ – can the NHS pull it off?
pharmafile | April 21, 2011 | Feature | | NHS reforms
Innovation is not a concept immediately associated with the UK’s national health service, but is now being promoted by the government and NHS leadership as being a central, crucial, component of its work.
But what exactly do they mean by innovation? Moreover, how on earth can the NHS even attempt to innovate when it is now struggling with the twin burdens of major structural reform and the need to produce £20 billion in productivity savings over the next four years?
Reform, re-design, innovation
Down the years, health ministers and senior NHS leaders have found the health service remarkably resistant to change, despite all their efforts to reform and modernise it through a succession of structural reorganisations and new policies.
The latest politically-led attempt to stoke the engine of change is current health secretary Andrew Lansley’s radical ‘Liberating the NHS’ reforms in England. By 2013, two layers of management (SHAs and PCTs) will be abolished, 75% of ‘bureaucratic’ jobs will be cut and financial control of the health service will be in the hands of GP consortia.
Many will say, quite rightly, that these incessant reconfigurations have often destabilised the system, but the idea of embedding a spirit of ‘modernisation’ or ‘innovation’ within the culture of the NHS has been around for at least 10 years.
The Labour government under Tony Blair set up the NHS Modernisation Agency in 2001 to help encourage front line clinicians to re-design services and to spread best practice.
This was succeeded by the NHS Institute for Improvement and Innovation, and it remains today just one of the ‘levers’ used by the NHS leadership to promote change to managers and clinicians.
This reflects a belief that the NHS needs to have a culture of continuous self-improvement built into its structures, rather than relying on periodic pressure to reform from the health secretary and Department of Health.
In this spirit of continuous improvement, the QIPP concept – Quality, Innovation, Productivity and Prevention – was introduced in December 2009.
Introduced in the last few months of the Labour government, this mantra was meant to help the NHS move away from the centrally-enforced target culture which had helped cut waiting times, and towards a more sophisticated, patient-focused health service capable of innovating and improving from within.
The story is, however, a little more complicated – despite its seemingly self-evident four-fold aims, QIPP has taken on a single overriding meaning – as the vehicle for the £20 billion productivity savings the health service must make in the next four years.
This clearly compromises the spirit of QIPP – if quality improvements must also always save money at the same time, this excludes service improvements which will improve patient experience, but also increase costs. As the pharmaceutical industry knows, innovation can sometimes help to lower overall costs, but just as often the benefits that innovation brings to patients comes at a price.
Despite some justified scepticism about QIPP’s cost saving agenda, it is clear there are indeed many clinical services where waste and inefficiency can be cut back, and quality of services improved. GPs are often named as being the best people to identify and eliminate waste, and this thinking informed Andrew Lansley’s decision to create GP consortia.
The leading groups, already up and running from the previous Practice-Based Commissioning system are already proving their ability to make significant savings while also improving services for patients (see box below).
The NHS leadership argues that faced with the reality of needing to make massive cost savings, NHS trusts should avoid using the simple ‘slash and burn’ cost-cutting approach which has traditionally been used. Instead it wants the NHS to harness reform and innovation to create cost savings.
Jim Easton is NHS national director for Improvement and Efficiency, and oversees the QIPP agenda. His message is that innovation in redesigning and improving services are essential to the future survival of the NHS.
“Innovation is the key to high quality care. Failure to find and implement such innovation is a lost opportunity now, and a threat to the future sustainable NHS care in the future.”
Technology-led innovation
The Innovation in Healthcare Expo, held in East London’s cavernous ExCel exhibition centre in early March, provided a forum for the NHS to share innovative practices, and for IT vendors, pharma companies, medical devices companies and other innovative sectors to showcase their wares. The companies included British Telecom (the main sponsors of the event) and Vodafone with their separate telecare and telehealth schemes, Pfizer Health Solutions, Philips Healthcare and Accenture, to name but a few.
Addressing the Expo, health secretary Andrew Lansley said: “The NHS has a long and proud track record of innovation that has driven major improvements in patient care. The Healthcare EXPO gives the NHS and UK companies the opportunity to showcase the advances and improvements they have developed and generate business for the economy, as well as the chance to learn from other countries.
“We need to foster a culture which supports innovation to improve quality and productivity. This is crucial for a modern NHS that puts patients first and achieves outcomes that are consistently among the best in the world.”
One significant means of promoting innovation is through The Commissioning for Quality and Innovation (CQUIN) payment framework, which is part of the QIPP programme. CQUIN is designed to allow commissioners to reward excellence, rather than maintain ‘business as usual’ (see below).
Technology uptake in the NHS
The process of greater uptake in non-pharmaceutical innovation is now being supported by NICE, which in recent years has expanded its role into looking at medical devices and procedures.
In a recent appraisal, NICE said the NHS could save £400m a year if a blood flow monitor was more frequently used during surgery.
NICE says the CardioQ-ODM device, which uses ultrasound, reduces complications and speeds up a patient’s recovery.
The watchdog body found the device cuts the length of time patients spend in hospital following major or high-risk surgery by an average of two days, and saves £1,000 with each use. It found fewer than three in 100 eligible patients are monitored using it, but NICE says if this was increased to 50 in 100 patients, it would save the NHS in England more than £400m a year. However, it must be noted that there are plenty of examples where the health service’s spending on technology has proven to be a poor investment – often because of poor procurement practices and lack of benchmarking.
Telehealth is one of the most notable areas of technological development which has been held out as a potential answer to the problems of 21st century healthcare – growing demand for monitoring of long term conditions, better, more personalised patient care while preventing the expensive admissions to hospital.
Learning the lessons from the NHS IT project – which attempted a ‘big bang’ approach to its introduction, small scale pilots are running around the country, and slowly gathering real-world data about its pros and cons.
OwnHealth, a partnership between NHS Birmingham North and East, UK Pfizer Health Solutions and NHS Direct is one example of a pilot project proving its worth. The scheme monitors patients with illnesses including cardiovascular disease, chronic obstructive pulmonary disease (COPD), hypertension and stroke, and has been running since 2006.
Patients use a home-based monitoring device, allowing clinicians to monitor blood pressure, weight, and oxygen saturation.
The pilot is now producing compelling data that it has helped to prevent costly admissions to hospital. A survey of 74 patients in the scheme suggested more than £270,000 had been saved by preventing these admissions.
Innovating in providing services can also mean disinvesting in technology – and as the NHS takes a more rational approach to its processes, the pharma industry will have to prepare itself to defend the contribution of its products.
THE SOUTH READING PATHFINDER CONSORTIUM
Originally starting in 2006 as a six-Practice-Based Commissioning (PBC) group, the Reading GPs were among the first to be selected to pilot the new system.
In January South Reading was one of the 177 pathfinder consortia. The consortium has grown to include a total of 21 practices, and was able to present a case study of how its work as a PBC group had already made significant progress.
South Reading were put forward for the pilot scheme after they demonstrated an ability to handle budgets and, more importantly for the government, how to make big savings across their practices.
They gave a number of examples where they had saved money in their area by relatively small changes in habit and outlook. One of the group’s lead GPs Dr Sudhish Sudhan presented a case study of how it has been able to cut A&E admissions for children under five by around half.
An audit commissioned by the group found that the majority of children sent to hospital were during GP hours and 45% of these did not require emergency care and could have been handled in the surgery.
To remedy this, the group created a short ‘traffic light’ leaflet for their practices that showed the levels of severity to look for in young children. Only when the symptoms were severe – or showed as red on the leaflet – should the GP send a child to A&E. Admissions to A&E are a major cost to the NHS and Dr Sudhan said each admission for his area cost £732 per child.
This simple change has helped save their local area tens of thousands of pounds and is just one of a number of new initiatives that have created savings totaling over £100,000.
The communication of these goals was crucial: all practices were briefed on where savings could be made and helped to implement them, demonstrating a real control and leadership from the GP heads.
Consortia and pharma
Dr Rosemary Croft, another a GP lead for South Reading consortium told Pharmafocus that medicines would be on the agenda to help make future savings.
“We have already drawn up a list of the top 10 most expensive elements within our practices, and medicines of course are on it.” She said that South Reading had ‘flirted along the edges’ of a relationship with pharma and believes that developing this will ‘be the way forward’ for her consortia.
This pathfinder shows how consortia are already thinking like a PCT and can manage tight budgets and larger managerial responsibilities. This will be important as a Department of Health says GP consortia will be responsible for making £4 billion – or 20% – of the £20 billion needed in efficiency savings during this Parliament.
Dissent in the ranks
The South Reading GPs were clearly up to the challenge about their new role and were looking forward to 2013 when they would gain the full budget from their PCT.
This feeling was not shared across the conference and the mood amongst GPs pointed to them more resigned than enthused to the reforms. One GP lead from Cambridgeshire who wished to remain anonymous told me that doctors were given a fait accompli: “It’s probably similar to voting in China – whichever way you go, you’ll inevitably end up with a Communist party at the helm. It’s the same with the reforms – many feel we can’t vote with our feet because otherwise where will we be [in 2013]?
“Our ultimate goal has to be to do the best for our patients, and rebelling against these reforms just isn’t in their interest, or ours.”
CQUIN – COMMISSIONING FOR QUALITY AND INNOVATION
The Commissioning for Quality and Innovation (CQUIN) payment framework is designed to allow NHS commissioners to reward excellence, rather than maintain ‘business as usual’. A current typical example of this would be a PCT paying an acute trust for services, but under the current reform plans, this responsibility would switch to GP consortia.
CQUIN works by linking a proportion of providers’ income to local quality improvement goals.
Most of these targets are set locally, but there are two national goals for 2010/11:
• Reduce avoidable death, disability and chronic ill health from venous-thromboembolism (VTE)
• Improve responsiveness to personal needs of patients.
Venous-Thromboembolism is a significant cause of mortality, long-term disability and chronic ill health. The goal of the established National VTE Prevention Programme is to reduce avoidable death and long-term disability from VTE. It is thought that there are around 25,000 deaths from VTE each year in hospitals in England. There is strong evidence that many deaths are avoidable if a patient is assessed for risk of VTE on admission to hospital, with appropriate prophylaxis then provided based on national guidelines.
This target clearly opens up opportunities for pharmaceutical companies which market drugs which prevent VTE, including the likes of Boehringer Ingelheim and its product Pradaxa, and Bayer’s Xarelto.
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