Working with a changing NHS

pharmafile | August 2, 2010 | Feature | Sales and Marketing |  HCA, NHS, commissioning, market access 

The first Healthcare Communications Association (HCA) forum of 2010 took place this April in London and looked at the central role of commissioning in the NHS.

The meeting came ahead of Andrew Lansley’s radical reforms to the health service, which arrived as a White Paper (Liberating the NHS) in mid-July.

Lansley’s game-changing proposals will give GPs the control of health system spending and sees PCTs being abolished by April 2013 – but the central challenges of commissioning remain, whoever is ultimately calling the shots.

The forum looked at some key challenges facing healthcare providers, and examined the perspectives of prescribing advisors and commissioners and how it is has affected  healthcare communications in the UK.

The meeting was chaired by Fiona Bride, director of market access at Huntsworth Health, who set the scene with an overview of the situation in the NHS.

Financing the health needs of the British public has long been an uphill struggle, but budget cuts and the impact of the current economic climate have compounded these woes. Furthermore, in an organisation that is already under considerable cost pressures, the NHS has been told it must save more than £4 billion within two years.

It is uncertain where these additional cost savings can be made without compromising quality of care. One thing, however, is certain – it is time to think differently about how healthcare services are delivered.

Next, Tim Dowdall, PCT associate director contracting, gave some insights into the world of healthcare commissioning, explaining some of the processes and highlighting some of the main considerations.

The commissioning cycle consists of three segments: strategic planning; procuring services; and monitoring and evaluation. The cycle begins in the strategic planning phase with an assessment of the population needs. This takes place when reviewing an existing service or when planning a new service.

On this basis, either a new service is assessed against need or a commissioning gap identified, or an existing service can be redesigned. The structure can then be decided, and the services procured.

After implementation, the service is audited to determine whether or not it is delivering adequately and appropriately, and is meeting the needs identified in the initial assessment.

While the aims of healthcare commissioning are to improve services, provide better patient outcomes and reducing costs where possible, all commissioning activities must take into account current NHS priorities, which are updated annually in the Operating Framework.

The 2010/11 Framework set priorities that aim to improve consistency through standardisation of pathways and reduced variability between regions. In addition, it aims to move care closer to home, and advocate the use of early and more upstream intervention.

The Operating Framework sets out the national priorities and enables PCTs to plan how they use their funding.

Currently, PCT strategic commissioning plans (SCPs) usually span five years, and describe the overarching priorities for the local population, for example to reduce smoking, obesity & STIs. (Note: It seems reasonable to expect this structure to remain when PCTs are abolished, but clearly it is too early to say how the new system will work in detail.)

The SCP also describe how a PCT will use its financial investments to achieve these goals. Each PCT currently publishes its SCP and annual operating plan on its website; whilst there are variations between PCTs, they all describe the short, medium and long term goals of the PCT.

Long term – strategic planning

The strategic level takes into account the bigger picture. For example, cost savings may be made through vertical or horizontal integration i.e., merging of community trusts and acute trusts or even the merging of community services.

This in effect reduces duplication of effort and resulting in combined efficiency savings. (Note: the 2010 annual operating plan laid out a 30% reduction of management workforce, following the recent announcement, this target has now been raised to 45 per cent).

Another way of achieving large scale transformation is by the introduction of joint ventures, which can be very successful at bringing NHS partners together to improve patient care. This could provide a potential opportunity for the NHS and the pharmaceutical industry to work together. Both have common ground, and by identifying the needs and priorities of both parties, their different expertise can be utilised to great effect. To this end, it is vital that the pharmaceutical industry understands the need for a more holistic approach – commissioners need to know that a drug will improve pathways and efficiencies as well as outcomes, rather than just presenting straightforward efficacy data.

It is also vital that pharmaceutical representatives understand the key players in the process, i.e. who are the key decision makers, and who’s involved in commissioning, before approaching stakeholders, for the best chance of success.

Medium term tactical planning

The Kaiser Permanente model describes the use of resources by a population, with those at the top of the pyramid using the most heath resource. Commissioners need to identify patients at the top end of the pyramid and consider if people in these tiers can be managed differently, in ways that are more appropriate, and cost-effective, to each.

One way of achieving this could be through the redesign of patient pathways. Designing better, more efficient, patient pathways can be achieved by involving different providers who are specialists at different stages. There is often duplication of effort when more than one party is involved in a patient’s care, but this can be avoided with vertical integration, which ensures that only one provider is responsible for each step in a patient pathway.

Another important tactic is to ensure that patients take the medicines that are prescribed to them. Concordance is a big issue – unused medicines not only waste the money spent on purchasing them, but if the patient does not take them, they have no effect, and this may result in increased healthcare costs further down the line due to complications or worsening of the condition.

Short term operational planning

There will always be potential for any PCT to be more cost-effective in its commissioning. There are several NHS tools available to support PCTs in prioritising its approach (e.g. Better Care Better Value indicators, NHS indicators).

Payment by Results (PbR), a system that reimburses hospitals for every ‘event’, e.g. consultation, scan, operation, that takes place, plays a big part in driving commissioning decisions to achieve efficiency gains.

The ability to provide services within primary care at lower cost than the PbR tariff provides a strong incentive to stop patients being referred unnecessarily to secondary care.

A good example of this is the provision of minor surgery in primary care. Many GPs are able to carry out minor surgery within their practices, and considerable cost savings can be made by keeping these patients out of secondary care.

Another example would be around reducing unplanned admissions to hospital. Realigning walk-in clinics, GP out-of-hours services, increasing GP opening times, and increasing use of pharmacists, could assist in reducing A&E attendances and admissions.

There are also several efficiencies to be made by prescribing generic medicines where appropriate e.g., statins. David Southern, a commissioner from the East of England, next discussed some of the challenges facing service provision in the NHS from the perspective of practice-based commissioners.

The NHS is a complex organisation, with different issues, health needs and patient case-mixes in different hospitals and PCTs. As such, when commissioning changes, it is vital that specific needs are understood.

Secondary Uses Service (SUS) data, obtained through PbR records, are a valuable source of information for resource planning. These data can offer insights into what resources are being used, when, how often, by whom, and how much they cost.

By this means, it is possible to map patient pathways, that is, track patients’ movements through the system for individual conditions.

Once identified, models can be used to analyse the impact of making changes to a pathway, for example, what would happen if one or more services within a pathway were moved out of secondary care, into the community.

Delivering services in primary care is often cheaper than delivering the same service from a hospital, and so cost savings may be achieved by implementing such a change.

However, there are a number of barriers to the implementation of new services. Not least that the NHS is a cautious, risk averse organisation that can be resistant to change.

The issue of resources is a significant one, as often, an initial investment may be required to set-up a new service before savings can be made, which may put pressure on short-term budgets.

In the case of implementing changes to an existing service, resources may need to be re-allocated to fit with the new service design.

Timing is an important consideration. NHS priorities are updated every year in the Operating Framework, and although many aspects remain the same, if service changes are not implemented quickly, priorities may change and the whole commissioning cycle must be re-started to ensure the project meets them.

Another challenge to effective commissioning is that there is no universal, clear commissioning process for the NHS. The practicalities of commissioning a service involve building a business case and presenting it to the key decision makers for approval, but there are many factors that need to be considered along the way, such as:

• How the service will be financed

• What is the commissioning route – will it put out to tender, or will an existing service be developed?

• Has approval from clinicians been sought for changes to clinical pathways?

• Have the needs of both the NHS and patients been assessed?

• Have patient opinions been collected?

• Have all relevant stakeholder groups been included in the consultation process?

There is an opportunity for pharma to work with the NHS in commissioning new services, where their product can add value to a pathway, through provision of expertise to help practice-based commissioners through the commissioning process.

Conclusion

The rising cost of healthcare is presenting an even greater challenge to an NHS trying to reduce spending. As a result, PCTs – and their successors following the reforms – need to look at where savings can be made though improved efficiency and streamlining of services.

The pharma industry needs to recognise that their drugs must provide more than just efficacy, but must offer improvements to the patient pathway as a whole. Where this is the case, there exists a great opportunity for pharma to be involved in mutually beneficial ventures to design and shape more efficient, cost-effective services.

Pharma can offer practical help to move the project through the commissioning process faster, by provision of supporting materials, e.g. patient leaflets, by offering relevant GP education, by working with stakeholders to produce referral guidelines, or by offering medicine concordance assistance to reduce drug wastage.

Questions raised

1) New drugs are available all the time – how do you deal with their impact?

Pharmacists work closely with practices to improve the efficiency of prescribing, and so need to understand the potential impact, including cost-effectiveness, of a new drug, but also of drugs coming off patent.

A holistic approach is needed to determine the effect on costs for nursing time, provision of community services, etc. However, from the practice-based commissioner’s perspective, new individual drugs are not especially important – the effect on the overall patient pathway is the most important consideration.

2) Concordance was mentioned as one way in which pharma can assist with reducing waste and improving patient pathways, are there any other obvious ways for pharma to assist?

It is important for pharma to understand the patient pathway, and the stages and coding of the disease. If treating earlier in a pathway can improve the pathway, then pharma can work with the PCT to implement this.

By understanding the commissioning process, and any local differences, pharma may be able to help smooth it out by offering practical help. Alternatively, they may help by producing supporting materials, such as patient leaflets, GP education, and referral guidelines.

Sometimes solutions to a service provision problem are already in place within the NHS somewhere, but sharing best practice can be a challenge. Pharma has the advantage of being able to operate across PCTs and share knowledge between them.

3) As many services are being moved out into the community to be taken up by GPs, who are generalists, is there a plan for GP education to help them provide these services better?

GP education is important. Traditionally, accessing secondary care expertise is routine and therefore moving provision of some services into primary care can be challenging. Moreover, GPs are generalists, and can’t be specialists in everything. One option is to run a consultant-led service within primary care, to train GPs, and therefore reduce inappropriate referrals. Referral guidelines with lists of tests/outcomes explaining when patients should be referred to secondary care can help achieve this.

Training for the referral management system helps GPs understand new pathways and changes in pathways that need to be implemented.

There is a potential role for pharma to assist with this, if they can see value in the pathway for themselves.

The HCA was founded in 2001 as an independent, not-for-profit organsiation with the stated aim of promoting excellence and best practice in the field of healthcare communications. Their mission is to provide an independent forum to promote best practice. For any information about the report released by the HCA, visit the HCA website: www.hca-uk.org.

The HCA would like to thank Lindsay Napier (Huntsworth Health) for writing up the initial report.