Longer-term budgeting and integrated care systems could transform the  NHS’ approach to medicines

Described by former Health and Social Care Secretary Jeremy Hunt as one of the ‘big moments in NHS history’, the recently announced 10-year plan represents a major new policy drive for the NHS in England.

Although the full content of the plan is not due to be revealed until the autumn, it has been confirmed that NHS England will receive a 3.4% per year, real terms increase in funding until 2023/24, to support its roll-out, frontloaded to 3.65% in 2019/20.
The 10-year plan will support the full integration of health and social care services and this joined-up approach will be key to enabling the significant efficiency improvements promised by Hunt.

In this article, we will explore what has been revealed about the 10-year plan so far; the way it is likely to unfold in the future, and the impact this could have on how pharma engages  with the NHS.

Priorities for the 10-year plan

In July, NHS England chief executive Simon Stevens identified five major priorities for the 10-year 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 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 Five Year Forward View (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.

Stevens confirmed that the ‘care redesign agenda’ set out in the 5YFV, aimed at integrating services, wouldn’t change and that new milestones would be set out to accelerate its speed. Integration programmes in the plan are expected to include Integrated Care Systems (ICSs), primary care networks, personalisation and integrated care organisations. He stressed the importance of releasing new funds by “radical” changes to large service areas which “could create headroom over and above the marginal increases” in NHS funding from government. This could involve reconfiguring outpatient services, potentially moving care closer to home in Local Integrated Care Partnerships or HUBS within primary care.

Another significant development over the summer was the appointment of Matt Hancock as the new health and social care secretary to replace Jeremy Hunt. Unlike his predecessor, Hancock will be responsible for both health and social care spending as the Treasury will be allocating a single budget for these services in November – yet another sign of the progression of the integrated care agenda.

Hancock who will, of course, be closely involved in the evolution of the 10-year plan, has listed his top three priorities for the NHS as technology, workforce and illness prevention, with the NHS receiving £487 million for technology.

Implications of long-term budgeting

When it comes to introducing new technology and innovation into the NHS, long-term budgeting is a real advantage. The 10-Year plan could, therefore, be good news for pharma companies struggling to sell innovative, and often expensive, products to low and middle management and clinicians who are currently constrained by in-year budgets. This is because the 10-year plan is likely to give NHS organisations a set of longer-term service level targets, rather than a single, annual financial control target.

Frequently, rebates have been used because they fit well with in-year plans. However, with longer-term budgeting, it would be easier to move to shared risk or outcomes-based schemes, since changes in patient management and outcomes could be monitored over periods of between two and five years, rather than one year which is a very short space of time in which to evaluate change.

However, the NHS will still have to meet targets every year, even within a five-year plan, so may seem two-headed in its strategy. Consequently, industry must manage itself within both of those constraints and show, for example, where it can deliver immediate savings – perhaps by reducing associated costs within a pathway – as well as where it can make a longer-term impact.
The NHS RightCare scenarios are a valuable resource for guidance in this area for pharma because they not only show what is happening in one year, but also what happens if you change the way a patient is managed for a particular condition, over a longer timeframe, usually five years. Getting it Right First Time (GIRFT) which looks at in-year efficiencies in the specialist units in hospitals, as well as longer-term efficiencies, is also very useful for pharma’s proposition demonstration. It covers a range of disease areas including cardiovascular, mental health, diabetes  and neurology.

Integrated health and social care budgets

The integration of health and social care budgets, combined with the move towards integrated healthcare systems, is expected to encourage commissioners to take an increasingly holistic view of medicines. It is expected that social care will play a key role in decision-making in the future; hence pharma could find that competition for funding comes from unexpected areas outside the healthcare industry.

A simple, but powerful, example of the impact of this change could potentially be applied to the management of asthma in deprived inner-city areas, where branded generics are currently one of the biggest competitors for many asthma treatments. If the social care budget was combined with the budget for medicines, then one of the biggest competitors for these asthma drugs could come from companies that sell antifungal paint and damp-proofing, since these products can have a huge impact on asthma prevention and management.

An example of the way in which this type of joined-up thinking is already taking shape within the NHS can be found in the area of mental health services, where there has been a big focus on medicalising patients in the past. One healthcare leader looking to change this recently commented that parity of esteem cannot simply be measured by combining mental health expenditure with acute expenditure, or expenditure on physical services, since social services expenditure may also be required.

The overarching message is that the 10-year plan will require pharma to become less focused on its own medicines and more focused on ‘appropriate patient care’. This means the industry must increasingly look beyond the cost and efficiency of a treatment at a single point in the care pathway and think instead about the whole care pathway. So, for example, what are the implications of failure rates for a drug? What are the implications of changing the care pathway further down the line due to a reduction in side effects from a medication? What are the implications for the rest of social services if a drug is increasing ambulation  for patients?
To work in this way, pharma also needs to engage more widely with decision-makers across the NHS – where, for example, STPs now encompass a variety of stakeholders ranging from representatives of Academic Health Science Networks (AHSNs), clinicians and pharmacists to local authority officers, charities and patient groups – and tailor its messages accordingly.

To achieve this, pharma must have excellent customer relationship management (CRM) data to identify key stakeholders and define their roles and responsibilities. It must also have clear insight into the needs, priorities and challenges of England’s   44 local healthcare economies, which are all working differently. This is often not easy as many STP ‘employees’ contracts are held in CCG personnel files, so they are hard to trace in a GDPR environment.

Tracking outcomes is also key and is being assisted by patient technology, such as diabetes monitoring kits, which are vital for concordance and improving outcomes.  Another exciting development is genetic ID which can help to identify the right patients for the right personalised treatments. Some pharma companies are already starting to associate themselves with innovative technology companies, in addition to supporting hospitals with patient profiling registers. The ability to offer tracking technology and patient profiling enables pharma to move closer to selling patient outcomes which are, of course, fundamental to the ethos of the 10-year plan.

The 10-year plan is in its infancy and the finer details have yet to be revealed. The priority for the NHS now is to assist key stakeholders in agreeing the way forward, communicating the vision to local teams and defining joint plans with incentives for each partner. If this can be successfully achieved, then there is real potential to de-silo the NHS, enable more strategic, joined-up thinking and deliver change at pace.

In the meantime, it is clear that integrated care systems that involve both health and social care will be key to the NHS in the long term. Pharma needs to understand this direction of travel and future-proof its business by identifying and engaging widely with key stakeholders; understanding the needs and priorities of local healthcare economies, and thinking more holistically about how medicines can add real value to the integrated health and social care mix.

Steve How and Paul Midgley are part of Wilmington Healthcare’s Consulting Team. For information on Wilmington Healthcare, log on to www.wilmingtonhealthcare.com