As the NHS’s integrated care agenda gathers pace, Clinical Commissioning Groups (CCGs) are under pressure to find new and more cost-effective methods of managing patients with complex needs in their own community.
In line with this, GP practices have been encouraged to combine forces in order to create integrated units that can each serve a patient population of around 30,000-50,000 – the universally agreed optimal size for Accountable Care Organisations internationally.
These integrated units are designed to enable staff from local community, mental health and acute Trusts, social care and the voluntary sector to unite, working together alongside GPs in order to provide joined-up care closer to patients’ homes and reduce hospital admissions.
How will local integrated care units work?
While the integration agenda is led strategically by the STPs and ICSs, the local delivery vehicles are the new ‘neighbourhoods’ of care. There have been various routes to achieving them so far, with GP practices uniting to form hubs, local integrated care partnerships, federations, super-surgeries, NAPC’s primary care homes and multi-specialty community providers.
Neighbourhoods are beginning to take services for conditions, such as diabetes, musculoskeletal (MSK) disorders and mental health, out of hospitals and into the community, and their multi-agency membership is key to achieving this goal.
In a “neighbourhood” in Nottinghamshire, for example, the district nurse lead, social care lead, housing lead and Citizens’ Advice Bureau representative are all based in the same office and work together, although they are employed by different organisations. They discuss case-oads together and hold joint meetings with patients in order to provide a completely integrated service.
So, for example, a diabetic patient in Nottingham who has lost a limb, would have all their health and social care needs assessed and managed by a single integrated team which would look at housing, social care and home help requirements, as well as diabetes care and insulin management. It could also arrange for district nurse care for serious necrotic ulceration, if needed.
Another interesting development that is occurring in line with neighbourhoods is inter-practice referrals. These were once frowned upon because practices were concerned about losing patients, however, the NHS is now providing contracts that encourage this style of working and enable the creation of ‘super centres’ within neighbourhoods that deal with particular therapy areas, in order to provide care more effectively within the community.
For instance, one GP practice in a neighbourhood could become a diabetes super centre, where diabetic patients are automatically referred for insulin adjustment and other treatment, while another practice may become an MSK super centre for steroid injections, physiotherapy, scans and related treatments. With the emergence of these super centres, it is expected that patients will be triaged rapidly to the appropriate local centre for many conditions. Indeed, they may not need to visit a hospital at all.
To help facilitate integrated care within neighbourhoods, different teams that once worked in isolation from each other and with separate budgets within a given therapy area, are beginning to merge and be funded by a single budget. As these teams become established, pharma may begin to see clear regional differences in prescribing where particular teams are covering specific localities more frequently.
Engaging with key stakeholders in neighbourhoods
As more care is provided via neighbourhoods, and hospital outpatients’ departments become less important, local NHS staffing roles are evolving. However, they are being dictated, to a large extent, by issues over recruitment, which is a major challenge facing the NHS. In fact, some NHS chief executives believe that recruitment is more problematic than finance – a view that is supported by a recent report from the charity Diabetes UK which indicated that 32 percent of the advertised diabetes specialist nurse (DSN) posts remain unfilled.
This means, for example, that in a diabetes super centre, there could be one just DSN supporting a group of practice nurses and pharmacists to manage care. Therefore, some nurses and practice pharmacists may take on wider roles in neighbourhoods and have more responsibility for prescribing. Practice pharmacists are already undertaking medication reviews on a regular basis for GPs across many disease areas, including diabetes. They are also running their own clinics in areas such as neurology.
Indeed, practice pharmacists are becoming increasingly prominent. More than 490 of them were placed in more than 650 practices across England in a pilot project which aimed to have over 2,000 clinical pharmacists working in general practice by 2020/21 – a ratio of one per 30,000 patients. Even though the funding is due to end in 2020/21, it is expected that the majority of GP sites involved in NHS England’s clinical pharmacist programme will still continue to employ practice-based pharmacists. Consequently, pharma needs to think about how care is being provided in the community and followed up, and whether pharmacists are going to be involved.
Identifying practice pharmacists and other key stakeholders within neighbourhoods is key. However, this can be challenging since, in common with ICSs and Sustainability and Transformation Partnerships (STPs), neighbourhoods are not legislated NHS bodies. In fact, sometimes the only way to identify key staff in these kinds of organisations is via the ‘attendance and apologies’ section in minutes and strategy documents embedded in member organisation board papers.
Pharma must take a similarly tailored approach when dovetailing its national market access strategy with neighbourhoods, since each one has unique needs, challenges and priorities. To understand them, pharma sales teams must be familiar with the individual plans of neighbourhoods and keep abreast of the latest developments via sources such as board meeting minutes and operational plans.
It is essential that pharma’s own sales teams working in secondary care, primary care and local market access are integrated and that they are thinking holistically as a variety of organisations increasingly work collaboratively with the NHS. In line with this, any proposition must offer good value to the CCG and wider community as well as the hospital.
Value propositions that demonstrate a reduction in handoffs or clinician time are of particular value for local integrated care pathways. A classic example of the way in which this can be achieved can be seen in the development of some biosimilar medicines, which are moving away from infusion to subcutaneous injections that can be easily administered by a less specialised workforce and in a community setting.
Some cancer treatments can also be administered in the community. For example, in 2016, a specialist cancer centre, The Christie in Manchester, launched a scheme to enable a number of cancer patients from across Greater Manchester and Cheshire to receive cancer treatment in their own homes.
Technology is also key to enabling more care to be provided in the community or to avoid the need for costly overnight hospital stays. For example, there is a new non-invasive technique for the treatment of prostatic hyperplasia, which can be used in a day case setting.
Services that engage patients in order to help them get the most out of their treatments are likely to play an increasingly important role in keeping them out of hospital and reducing their overall reliance on the NHS in the long-term. One example is Oviva – a dietetics service provider using technology to improve treatment of diet–related diseases.
The integrated care agenda is stimulating the biggest change within the NHS since its inception in 1948 as health and social care services – which were once provided by multiple organisations with multiple budgets – are being merged to serve the needs of local populations more effectively.
In order to help the NHS deliver this kind of integrated care within local communities and reduce costly hospital stays, pharma must think holistically across the whole care pathway and ensure that its products meet the needs of the wide variety of stakeholders in the new NHS neighbourhoods.
This requires an in-depth knowledge of the needs and priorities of individual local health economies in tandem with a strategic understanding of where a product fits into the overall care pathway and how it could bring cost savings and improve patient outcomes in the long run.
Steve How is a member of Wilmington Healthcare’s Consulting Team. For information on Wilmington Healthcare, log on to www.wilmingtonhealthcare.com
