Working with the NHS in austerity
pharmafile | May 20, 2013 | Feature | Manufacturing and Production, Medical Communications, Research and Development, Sales and Marketing | NHS, atkin, austerity, reforms, wellards
The National Health Service, perhaps the UK’s most deeply loved institution, is facing a double threat.
On one hand, there are the effects of cost-savings measures, which become ever-more necessary as the UK struggles to exit its long-running economic slump.
On the other, is increasing demand for health services. Once productive baby-boomers are turning into demanding and savvy elderly consumers of healthcare, each of whom have an average of two or three long-term conditions that demand to be managed by new technologies.
These are things we would be talking about all the time, if the Coalition government had not launched its controversial package of health reforms – even when we’re meant to be discussing austerity, the NHS reforms, which came into effect on 1 April come back up to the top of the agenda time after time.
There’s no separating the two issues, and the recent Wellards forum on austerity reflected the point.
Fears of a budget shortfall
Senior Nuffield Trust research fellow Ruth Thorlby from the Nuffield Trust explained that flat income and increasing demand will require big changes in order to prevent a large funding gap, and that a substantial shortfall is likely in the early 2020s.
She then turned to the health reforms, considered the changes and institutions – and concluded it was difficult to know how it would all work.
Professor James Raftery, professor of health technology assessment at the University of Southampton reviewed the history of NICE, discussed the arguments for lowering the cost per quality of life year, concluded that was a distinct possibility, explained why it was difficult to see how value-based pricing will work – and cast doubt on whether it would be brought in.
Professor Alan Maynard considered the history of health service reform going back to the mid 1970s. He argued that none of the major reforms he’s seen during his long career had been supported by evidence or properly studied in a way that would contribute to future reforms – and that because of the lack of evidence it was difficult to predict what the real effects of the latest round of reforms might be.
And so it fell to the day’s star speaker, the confident and determined Dr Shane Gordon, GP and chief officer of NHS North East Essex Clinical Commissioning Group (NEECCG) to explain how his organisation is going about achieving its aims, where everyone else fits in, and what the NHS’s suppliers in pharma should do about it.
Gordon is credited with having been one of the influential GPs who influenced the way previous secretary of State Andrew Lansley set out his health service reform.
Role-wise, as well as the NEECCG’s chief officer, he’s also a member of the leadership group for the organisation NHS Clinical Commissioners, the voice of CCGs formed by a partnership between the NHS Alliance, NAPC and NHS Confederation.
In that job he must have the best overview around of what is happening in CCGs, the organisations that took control of much of the NHS budgets from April.
The challenges he went on to outline are huge, without question. On the money side, the effects of austerity have been felt in various ways, and one has been big cuts in spending on health service management, from £4.5 billion a couple of years ago down to approximately £3 billion now.
Even alone this reduction would raise serious management issues.
“It’s a swingeing cut in the commissioning capacity of the NHS. One of my biggest challenges is how to continue to do something worthwhile,” said Gordon. His audience was left in little doubt that spending so little on managing such big budgets is a fool’s economy.
Social care funding
Cuts come in various other ways too. “The elephant in the room is social care. Social care has taken at least a 30% cut in funding in the past year and will continue to feel the burden of protecting the NHS from having its spending going down. The challenge is that every patient who is not maintained in their own home or in residential home care is going to end up on my doorstep.”
There have also been a series of more overt demands on CCG budgets, of which the Specialised Commissioning Group has made only the latest.
“The SCG has just appropriated £20m of my budget and is now telling me they’re not going to pay for everything that was paid for previously with that £20m. It will take some time to iron out these details.”
With money so tight and CCGs facing so many and such varied challenges in their first year, failures are almost guaranteed wherever the commissioning organisations have any cash problems.
Some aspects of the reforms are not working out in the most helpful ways. The intended role of clinicians in the reformed health service looks like being a challenge for some time to come, as does the role of the clinical networks.
“Clinical commissioning looks to redress the balance between professional managers and those who deliver the service. However, of 211 CCGs, only 47 of us leaders are clinicians.”
This needs to change. “If we don’t get the wind blowing in the right direction there is a danger we will not be able to bring with us the colleagues who we need to do the changing.”
Clinical networks are also undergoing radical change and some of their work is going to be disrupted. “In Essex we’ve got a well functioning stroke network, and a cancer network. But none of the staff from those organisations will be in the new networks, so we’ve got a sudden loss of continuity in the advice we get on some of the most high impact decisions we make about pathways.”
Also, there’s a big question about the new system’s ability to deal with the hospitals. “We need to change the acute hospital landscape, but we aren’t very good at doing that because of the huge political opposition, and I don’t see that going away any time soon.”
Then there’s the issue of the competition regulations. Dr Gordon observed that the DH had amended the section 75 rules to make it possible for CCGs to not have to tender every contract, but it is not yet clear whether the issue has gone away.
“It will be interesting to see whether that gives us the freedom we want or if we will have to use the market much more than we would prefer to,” he said.
And then there are the CCGs themselves. In north-east Essex, GPs have been engaged in commissioning for many, many years and the area’s new CCG has a reasonably good grip on what’s going on, he said. But many others are not so well sorted out – and in effect NHS England local area teams will run those organisations for some time.
Although NEE is further down the road than many CCGs there are still many challenges, and the organisation has to deal with being accountable to and regulated by so many organisations.
The CCG is accountable to its member practices, which can remove the elected members of the board. That creates what he calls an ‘interesting’ tension – a lot of the work the CCG has to do involves improving the quality of primary care and in some cases supporting its reconfiguration to ensure sustainable services.
Further, the CCG is accountable to the NHSCB. Despite being a single organisation it appears to operate at three levels – the local area team, the regional office and the national office. “Much of it looks very similar to what it looked like before,” he said ruefully, “only we have fewer people”.
The CCG is also indirectly accountable to local government, via the health and wellbeing board. “Although the health and wellbeing board doesn’t have a stop-go type approval, if they don’t approve our plans the NHSCB won’t sign them.
“So we have to align our priorities not only with the national health system but also with the priorities of local government.” Thankfully, he said, NEE’s dialogue with the HWB had been interesting and productive.
Then there are the regulators: Monitor’s job is to regulate commissioning and to ensure that the best value is obtained through the market. “There’s this constant anxiety in commissioning that Monitor will come in and say: ‘You didn’t use the full market process.’ We’ll see how that works.”
Can care be integrated?
NEE has determined its own way forward, starting with a five-year plan that addresses the way commissioning has traditionally been done. For one thing, healthcare and social care will no longer commissioned so separately.
Services are to be dealt with in a completely new way. Traditionally, everything in NEE has been bought in small segments. The three CCGs across North Essex calculated that some 3,000 separate contracts were currently in place providing services for its population of 1 million.
“If we take the approach of just renewing contracts, we are going nowhere fast,” says Gordon. “We’ve decided instead to look for integration. I don’t mean mergers, but what the journey looks like to the patient.”
The plan is to buy services that describe the longitudinal needs of patients, not the organisational boundaries that contracts follow at the moment. By 2017/18, the aim is to contract for non-acute care with a number of ‘whole-care’ providers.
The organisations involved will have to provide a care package that attracts patients to take their personal healthcare budget with them to that organisation. Patients will be able to choose between different offers that are not too far apart geographically.
There will bring a strong incentive to keep people out of hospital, which organisations can put in their bottom line or reinvest in care. Gordon and his colleagues are thinking hard about how to organise new contracts that line up with this aim and deliver a new level of integration.
He expects NEE will be putting out a series of significant contract ‘bundles’ in a year’s time, but local providers are getting advanced notice now.
“My hope is they will wake up and say if these came out now we wouldn’t win them, because they wouldn’t be able to deliver that level of integration. We shall see.”
Dr Shane Gordon
• On quality of life: “Francis will have a profound effect on the way we work. If it does what it’s supposed to do we might end up looking at the right outcomes instead of the wrong ones.”
• On CSUs: “Relations will be under critical test in the next year, and we’ll see how many CCGs are buying commissioning support from the same CSU at the end.”
• On personal health budgets: “New treatments involve large ‘numbers needed to treat’ (the number of people who have to have treatment for one person to benefit), but if you give the money to patients they might try one thing for a while – but if it doesn’t feel like it’s delivering benefit, they’ll try something else or stop it.”
• On local government: “Health and wellbeing boards are only just discovering that they’ve got muscles.”
• On CCGs: “CCGs are all different. They’re each at different stages of development, and while they’re all trying to achieve the same broad ends, they are going about them in a variety of ways. They must be studied individually. When you’ve learned about one CCG’s priorities and plans, that’s it – it is just one CCG. The rest will be different.”
• On approaching CCGs: “Don’t bombard us with communications. Be soft and subtle; this is diplomacy and it is long-term. Do not over-promise when you offer support, and make sure you can deliver.” Also: “Do your homework. There is lots of intelligence about what’s going on in local areas, that tell you what value we have to deliver.”
• On outcomes: “Do not ignore quality of life. Where we’re going with value is as much to do with quality of life as hard clinical outcomes. Improvements in quality of life are critical.”
• On what CCGs are looking for: “Anything you can offer that supports the shift of services is really invaluable, because restructuring hospitals from the top down is really, really hard and politically incredibly difficult. Show me how it saves money or fits into a system of care that I can understand.”
Related Content
A community-first future: which pathways will get us there?
In the final Gateway to Local Adoption article of 2025, Visions4Health caught up with Julian …
The Pharma Files: with Dr Ewen Cameron, Chief Executive of West Suffolk NHS Foundation Trust
Pharmafile chats with Dr Ewen Cameron, Chief Executive of West Suffolk NHS Foundation Trust, about …
Is this an Oppenheimer moment for the life sciences industry?
By Sabina Syed, Managing Director at Visions4Health In the history of science, few initiatives demonstrate …
