At the start of the year, the NHS set out its vision for the future in its Long Term Plan, which has significant implications for all local health economies in England in terms of how services are designed and delivered.
For some local health economies, particularly those that had already become Integrated Care Systems (ICSs), the Long Term Plan validated their work to date; for others, particularly those in financial recovery, it requires a shift to a very different style of working.
In this article, we will explore how the NHS has changed over the past year, particularly with regards to structure, finance, commissioning, outcomes and key performance indicators (KPIs). We will also assess how this is affecting market access for pharma.
Structure
In the Long Term Plan, the NHS reaffirmed its commitment to integrated care, stating that, by April 2021, all areas of England will be covered by an ICS with typically just one Clinical Commissioning Group (CCG) per ICS area.
In June, three further areas were designated as ICSs by NHS England. They joined the 14 existing ICSs and left 28 Sustainability and Transformation Partnerships (STPs) remaining. CCG mergers have continued in 2019 and although the final expected number of CCGs is still unknown, it is possible that there could be a reduction from the current 191 CCGs to around 60-70.
The introduction of Primary Care Networks (PCNs) in July, which are the building blocks for Integrated Care Partnerships (ICPs), was another fundamental structural change. PCNs are central to moving more care out of hospitals and into the community, which is a key aspiration of the Long Term Plan.
Finance
Some ICSs have already dispensed with standard Payment by Results (PBR) contracts and are operating more integrated budgets. These systems are trailblazers which all other health systems are under pressure to emulate within the next few years.
They include Dorset ICS, whose chief system integration officer, Dr Phil Richardson, was guest speaker at a Wilmington Healthcare webinar earlier this year. During the webinar, Phil explained how Dorset ICS runs “a family budgeting system”, where money has already moved from one organisation to another to achieve balance across the system.
The move from PBR to variable, outcomes-based and block contracts is creating a more complicated landscape in terms of the relationship and money flow between commissioners and providers, and also from the perspective of understanding how PCNs and ICPs take on some of the lower level commissioning and contracting functions of CCGs. Without local insight and research, it is going to be harder for pharma to see where money goes, who receives it and how it is spent during this transition.
A knock-on effect of outcomes-based and block contracts, and the integrated approach that underpins them, is that hospitals will no longer compete against each other. Instead, hospitals within ICPs are jointly looking at the whole health community, including all other providers to define how they can serve it better in partnership with strategic commissioners across an ICS footprint.
Commissioning and hospitals
Although the NHS is committed to ICSs, in some parts of the country, such as London, which have large and long-established teaching hospitals, it is likely that these hospitals will drive the local care agenda.
These hospitals will still have a fixed budget and they will have to determine how to manage it. It is likely that they will want to do as much work as possible in the wider community since hospital running costs are so high.
Also, on the hospital theme, in a bid to improve surgical services, the Long Term Plan promised to continue backing hospitals that wish to separate urgent and planned care into different sites which are known respectively as ‘hot’ and ‘cold’ sites, and this style of working has been increasing this year, eg in North Tyneside.
Bringing care closer to home
Reducing hospital stays and bringing care closer to home are key objectives in the Long Term Plan and also its predecessor, the Five Year Forward View. Some innovative healthcare organisations have already successfully shown how it can be achieved. For example, Calderdale and Huddersfield NHS Foundation Trust has a day-case digital knee replacement surgery where some patients can have an operation and be discharged within 24 hours. Rehabilitation therapists can then remotely monitor the patient’s progress at home, via wearable technology in the form of a sensor worn by the patient.
In Cheshire and Merseyside, some specialist services have been reconfigured to improve patient recovery times and outcomes. For example, a new hyper acute rehabilitation ward at The Walton Centre now treats patients at a much earlier stage following a traumatic head injury. A new network team co-ordinates a staged pathway of care which includes specialised rehabilitation at Walton and in three ‘spoke’ hospitals and in community settings.
In the South-East, a Maidstone and Tunbridge Wells NHS Trust (MTW) project called ‘Improving Patient Flow’ has introduced a number of innovative measures to improve emergency care services. These include extending the use of ambulatory services and frailty units, securing beds in the community to care for patients waiting for social services support, working collaboratively with partners to help suitable patients return home to finish their acute care via the new Hospital @ Home scheme and improving the efficiency of operating theatres and outpatient clinics.
Key Performance Indicators (KPIs)
The NHS Oversight Framework for 2019/20 has replaced the provider Single Oversight Framework for hospitals and the CCG Improvement and Assessment Framework (IAF), which set annual targets for CCGs. It means that hospitals and CCGs must now work together to deliver on KPIs across their STP/ICS footprint.
Under the OF, KPIs are being set for individual disease areas. For example, indicators and targets have been set for around 20 different areas for cancer.
Market Access
Local variation in progress on integrated care, even among the first wave of ICSs, has already been making market access challenging for pharma. However, further change is on the horizon as all health economies are due to produce new plans for their localities in response to the Long Term Plan. The deadline for these plans was originally set for mid-November but it has since been extended for at least another month.
Some ICSs are simply retrofitting plans from their original STP and adding in Long Term Plan priorities. However, other health systems have to make more significant changes to their original STP plans. The new plans are highly significant since they may impact on which drugs are used and how care pathways are provided. This means that, to a large extent, we are ending the year on a ‘wait and see’ basis.
It will be essential for pharma to conduct a locality by locality analysis of the new STP/ICS long term plans to define how clinicians fit into networks and who will be in the new decision-making units. ICSs have certain areas that they must focus on under the Long Term Plan, such as diabetes, cancer and respiratory disease. Pharma needs to define what is happening in these areas and other key workstreams and identify the people who are leading these ‘programmes’.
The same applies to STPs where pharma also needs to identify the clinical leaders who are tasked with managing transformation and who will be leading workstreams.
Pharma should also follow the specialist organisations that are working alongside ICSs and STPs on specific disease areas. So, for example, for cancer there are 19 Cancer Alliances, while in diabetes and respiratory disease there are Strategic Clinical Networks. Although the Cancer Alliances and Strategic Clinical Networks have different ways of working, they will all report to ICS/STP boards and they will have a major influence on how services should be delivered.
Conclusion
We started the year with the publication of the highly anticipated Long Term Plan which set the pace for the continued move towards ICSs and underlined the NHS’ preventative and population-based approach to health and social care.
There are golden opportunities for pharma to support local health economies in delivering key elements of the Long Term Plan. But the local NHS landscape is becoming increasingly complex and more change is on the horizon in 2020.
The changes that we have seen this year have underlined the need for pharma to take an increasingly tailored approach to customer engagement and seek to understand the goals and aspirations of individual health economies as they continue to evolve in line with the NHS’ long-term vision.
Paul Midgley is director of NHS Insight and Oli Hudson is content director, both at Wilmington Healthcare. For information on Wilmington Healthcare and to find out more about the latest developments in the NHS, including the role of PCNs, visit www.wilmingtonhealthcare.com
