The NHS has been taking an increasingly joined-up approach to care during 2018, significantly altering how it works with pharma

In 2018, four more Sustainability and Transformation Partnerships (STPs) were given the green light to form Integrated Care Systems (ICSs) and there was a renewed commitment to this joined-up style of working from NHS England’s chief executive, Simon Stevens.

Reducing unwarranted variation in patient care and outcomes, and getting better value for money for drugs and other goods, have also been key priorities in 2018. The ICS model with its single regional control total – which is an indicative pooling of resources – supports these objectives.

However, due to current legislation, ICSs still have to deliver their in-year financial budgets. This creates organisational tension because while the transformation teams are developing new integrated services and models of care to deliver the Five Year Forward View (5YFV), other teams, which often include medicines management, are focusing on in-year savings.

However, change always creates opportunity and pharma can play a part in the transformation process by keeping clinicians abreast of the changes.

Integrated care

There are now 14 designated ICS areas in England following an announcement in the spring that a further four STP regions would make the transition – namely Gloucestershire, West Yorkshire and Harrogate, Suffolk, and North East Essex and North Cumbria. These high-performing areas, which have taken on broad learnings from NHS vanguards, are leading the way on whole population contracts.

This approach sees one provider or a group of providers responsible for all the health and social care needs of a defined population in order to improve outcomes and reduce costs. In line with this, ICSs have agreed to a single control total that allows organisations to indicatively pool their budgets to consider the whole pathway so that system changes can be made. One example of this is the reduction in outpatient services, which come from hospital budgets, and the increase in follow-ups in the community.
The importance of local integrated care systems was highlighted by Simon Stevens, in July, when he announced priorities for a 10-year NHS plan, now known as the long-term plan. Stevens confirmed that the ‘care redesign agenda’ set out in the 5YFV, and aimed at integrating services, would not change and that new milestones would be set out to accelerate its speed. Integration programmes in the plan – which had not been published in full at the time of writing this article – are expected to include ICSs, primary care networks, personalisation and integrated care organisations.

In October, Stevens called for legislation to accelerate the progress of the long-term plan in areas including “the ability for local NHS organisations to function in a way that is more consistent with the move towards systems working [and population health].”

NHS Neighbourhoods

While the integration agenda is led strategically by the STPs and ICSs, the local delivery vehicles are the new ‘neighbourhoods’ of care, which come in various forms. They involve GP practices, often working alongside other providers such as hospital and community Trusts and social services uniting to form hubs; local integrated care partnerships; federations, super-surgeries and NAPC’s primary care homes.

Within some of these neighbourhoods, we are seeing the district nurse lead, social care lead, housing lead and Citizens’ Advice Bureau representative based in the same office and working together, although they are employed by different organisations. They discuss case-loads together and hold joint meetings with patients in order to provide a completely integrated service.

New NHS priorities

In the summer, Stevens identified five major priorities for the long-term plan. The first priority was mental health, especially services for children and young people, and potentially core crisis care. The second priority was cancer, where Mr Stevens said many aspects of screening services would be overhauled.

He also announced that there would be three new priority areas that were not a focus in the 5YFV. One of them was cardiovascular disease – strokes and heart attacks. The other two were a renewed focus on children’s services and prevention and inequality as they affect children, and new objectives for reducing health inequalities.

The new health and social care secretary Matt Hancock, who was appointed this year to replace Jeremy Hunt, will be closely involved in the evolution of the long-term plan. His top three priorities for the NHS are technology, workforce and illness prevention.

Reducing unwarranted variation

Unwarranted variation in expenditure and efficiency is a major problem that the NHS has continued to tackle this year via a number of initiatives, including the introduction of 11 procurement towers designed to help save money and reduce variation in the price paid for all types of goods.

NHS RightCare has also been furthering its work on best practice scenarios, which not only show what is happening with care in a single year, but also what happens if you change the way a patient is managed for a particular condition, over a longer timeframe, across the whole pathway of care.

Another key initiative, Getting It Right First Time (GIRFT), has continued to be very active this year. It is assessing surgical and medical specialties and producing reports and recommendations. A key outcome of this work has been the centralisation of some services in order to improve outcomes. For example, earlier this year, several Trusts said they now had plans to centralise vascular surgery. This followed a visit by the GIRFT clinical team to all 70 vascular surgery sites across England and subsequent recommendations about the minimum number of procedures they should perform to remain viable.

Best value biologics

The NHS’s best value biologics programme, which also aims to get value for money, deliver optimal care and improve patient outcomes, reached a major milestone in October when adalimumab – which has the highest global turnover of any medicine – came off patent in Europe.

Regional Medicines Optimisation Committees (RMOCs), which were launched last year, have been playing a pivotal role in working with NHS commissioners and providers on best value biologics in 2018 and helping them to prepare for Adalimumab’s patent expiry, and the introduction of biosimilars estimated to save £150m a year.

Clinical engagementA good practice guide for commissioners on the NHS England assurance process for major service changes and reconfiguration was updated in March. It puts front-line clinicians at the heart of driving and assuring major service change, based on the best available evidence.

However, despite the intentions laid out in NHS England’s ‘Planning, assuring and delivering service change for patients’ most clinicians do not know what is happening unless they are part of the executive team that is involved in transformation. Consequently, many clinicians do not understand how the ICS ethos applies to them. As a result, there can be friction in the frontline, where in-year objectives are “at odds” with what service transformation leaders are planning for the long term.

There is, therefore, a big opportunity for pharma to empower clinicians by engaging with them on service transformation. This could include, for example, regular catch-ups with clinicians to update them on what is happening.

A holistic approach

Pharma needs to position its offering in line with NHS best practice recommendations. Thinking about the cost of a product across the whole care pathway is key, particularly when it involves saving workforce time, or enabling care to be provided away from hospitals, or even in patients’ homes. This is particularly important as the NHS comes under pressure to reduce spending on bank nurses and locums, and makes greater use of clinical pharmacists who are taking on some work previously done by GPs and nurses.

So, for example, subcutaneous biologics could be shown to have key cost saving advantages over those that need infusion. Similarly, drugs that are more expensive but have proven low failure rates could also be shown to generate the kind of long-term savings that integrated care systems require by negating the need for more NHS care further down the line.

The integrated care agenda is stimulating the biggest change in the history of the NHS as health and social care services – that were once provided by multiple organisations with multiple budgets – are being merged to serve the needs of local populations more effectively.

ICS level control of total indicative budgeting is now giving ICSs a clear view of where and how their money is spent; while key NHS initiatives such as RightCare, GIRFT and Best Value Biologics aim to help all NHS organisations adopt best practice strategies and processes that will save money and improve patient care and outcomes.

Amid these changes, there is scope for pharma to play a key role in the NHS transformation agenda by aligning its own products with NHS best practice; thinking about how a product can save money across the whole care pathway and engaging with clinicians and other key stakeholders to help them navigate and manage change.

Steve How, Paul Midgley and Oli Hudson are all part of Wilmington Healthcare’s Consulting Team. For information on Wilmington Healthcare, visit