Last issue we explored how Clinical Commissioning Groups (CCGs) and GP practices were being forced to work in more collaborative and joined-up ways as the NHS moved towards Accountable Care Systems, which have since been rebranded as Integrated Care Systems (ICSs).
To succeed in this new commissioning landscape, pharma needs to understand the local model of care delivery within the 44 Sustainability and Transformation Partnerships (STPs), and how this is likely to be adopted by the newly emerging ICSs. The industry also needs to get on board with new care models that are being developed for different disease areas.
Understanding local population needs is key
In 2016-17, the NHS received an additional £1.8 billion Sustainability and Transformation Fund to help it prepare for the need to survive on significantly lower funding growth from 2017-18 onwards and become more sustainable.
Unfortunately, however, a recent report from the National Audit Office shows that this additional funding has been spent on coping with existing pressures rather than helping the NHS get on a financially sustainable footing. Consequently, while the money has helped the NHS to improve its financial position, it is still struggling to manage increased activity and demand within its budget, and it has not met NHS access targets.
According to the latest NHS Planning Guidance 2018-19, the Sustainability and Transformation Fund is to become the Provider Sustainability Fund (PSF), with total funding of £2.45 billion (up from £1.8 billion currently). Access to 30 percent of the fund remains linked to A&E performance. A new £400 million commissioner sustainability fund (CSF) will also be introduced to enable CCGs to return to in-year financial balance.
Achieving required efficiencies has been forcing STPs to look beyond the integration of buildings and services to determine how they can manage the needs of their entire healthcare population. Patient outcomes are the crucial yardstick by which their success will be measured, and they cannot assume that more interventions will generate better results.
STPs need to profile their local population to understand the burden of disease. They must also analyse how their services are performing and where patient pathways could be changed in order to improve outcomes and save money. Promoting the self-care agenda will form part of a more preventative approach to healthcare; while co-production of new pathways with patients involved from the start is now seen as the best way to optimal design.
From STPs to ICSs
Eight areas in England have already been chosen to lead the way in forming an Integrated Care System (ICS), originally known as an Accountable Care System (ACS), which will replace STPs in those places.
Accountable Care Systems have sparked legal action by a group of campaigners, including Professor Stephen Hawking, who claim they will lead to the privatisation of the NHS.
Following controversy over the term ‘accountable care’, planning guidance issued for 2018-19 from NHS England and NHS Improvement recently stated that ICS will be the ‘collective term’ for the devolved health and care systems in Greater Manchester and Surrey Heartlands, as well as the eight shadow accountable care systems.
The planning guidance document said that the eight shadow ICSs would not be ‘considered ready to go fully operational’ until they produced a single system operating plan for the coming financial year. These plans should ‘align key assumptions on income, expenditure, activity and workforce’ and system leaders within the ICS are expected to take an ‘active role in this process’.
The systems will operate under one system control total allowing more flexibility within organisations’ budgets as long as the system produces a zero net financial balance. This allows for the potential decommissioning of some traditionally high payment-by-results earning hospital services to more cost-effective integrated pathways. It will also mean that organisational differences in prescribing costs between hospital contract and prescription tariff will now bow to whole-system prescribing costs.
The guidance document also confirmed that NHS England is still accepting bids from areas that wish to be included in the ‘next cohort of ICSs’ and intends to have reviewed all applications by March 2018.
ICSs must focus on four key areas including ‘more robust’ arrangements between STP organisations; a focus on managing population health; delivering ‘more care through re-designed community and home-based services’; and systems to take ‘collective responsibility’ for financial and operational performance.
Patient outcomes and value to the system will continue to be as important as cost because outcomes will be directly tied to the business model of the ICSs. New care pathways will be required to make the most of ICS resources – opening the door for technological solutions that can support providing care in the lowest intensity setting.
Formularies are likely to be ICS-wide with one committee making the decisions for the whole territory and powerful NHS Trusts will be key organisations within the ICS for market access. They will still take guidance from NICE and RMOCs.
How should pharma adapt?
In the midst of these fundamental changes, pharma needs to understand the local models of care delivery within specific areas and get on board with different care models. It also needs to stress the preventative elements of therapies in business cases.
Data is key to this approach and given the fact that the NHS has historically struggled to capture, procure and analyse its own patient population and pathway data, this is a key area where pharma can assist.
Hospital activity data, such as Hospital Episode Statistics (HES) can provide vital insights into the way local services are performing and the current cost of admissions, which could be offset with more appropriate and preventative service provision.
Interviews with stakeholders, such as STPs, ICSs and patients, can also be invaluable to gather insight on trends, gaps or inefficiencies in patient care in a variety of priority and non-priority disease areas.
These insights can be used to highlight the burden of disease; identify variations in patient outcomes and provide evidence for change in therapeutic areas. They can also help the NHS gain a clear understanding of the impact that pathways have on patients’ experiences and outcomes, and highlight areas of best practice and opportunities for improved efficiencies.
For example, an English HES data analysis published last year, by Wilmington Healthcare and the charity United Kingdom Acquired Brain Injury Forum (UKABIF), showed that Traumatic Brain Injury (TBI) is a major threat to older people. The study found that 40 percent of hospital admissions in 2014/15 for TBI were for people aged over 75 and many of these injuries were sustained as a result of trips and falls.
The authors of the study concluded that raising awareness within primary care of these issues could help to tackle the problem by encouraging a more preventative focus in frailty strategies for the ageing population.
The constant pressures placed on the NHS show no sign of abating. Indeed, as the National Audit Office’s recent report suggests the NHS is struggling to keep services running, let alone transform them. Yet service transformation is essential for long-term sustainability.
STPs and the newly emerging ICS models will be key to driving such change within the NHS by allowing it greater flexibility when responding to challenges in specific localities. So, too will the increased focus on preventative care and self-care.
As the NHS endeavours to become more fleet of foot, pharma needs to keep abreast of the new local care models that are emerging and find ways to support them. Understanding and analysing local population data will be critical to engaging with STPs and ICSs, and enabling pharma to ensure that its products and services will help STPs and ICSs achieve their sustainability and transformation goals.
Paul Midgley is director of NHS Insight, Sue Thomas is CEO of commissioning excellence and Steve How is business development director, all at Wilmington Healthcare. For information on Wilmington Healthcare, log on to www.wilmingtonhealthcare.com
