At the start of 2019, the NHS set out its priorities in its Long Term Plan, which aims to ensure that the additional funding announced last year, to mark its 70th birthday, is spent wisely over the next decade. The document provides a blueprint for the development of plans for local NHS organisations.
The NHS, which is to receive an extra £20 billion a year by 2023, reaffirmed its commitment to integrated care in the plan, stating that, by April 2021, all areas of England will be covered by an Integrated Care System (ICS) with typically just one Clinical Commissioning Group (CCG) per ICS area.
It also gave more substance to other innovative ways of working, such as moving care out of hospitals and into the community and driving digital transformation, which have both been initiated in parts of the NHS.
Integrated care
There are three levels of integration within the NHS. ICSs cover a population of one to three million and within them there are Integrated Care Partnerships (ICPs), covering approximately 500,000 people, and Primary Care Networks (PCNs), covering populations of 30,000-50,000.
As the NHS refocuses care from organisations to place, ICSs will see aggregating CCGs strategically commissioning from primary and secondary care providers united within regions as ICPs. These integrated care systems will also bring external organisations, such as local authorities and social care, into the mix within ICSs, though it may be a while before they become legal entities.
The plan promises £4.5 billion of new investment to fund expanded community multidisciplinary teams within ICSs, which will include organisations such as the police and the Citizens’ Advice Bureau (CAB). Acute care nurses — in areas such as mental health and cardio-vascular rehabilitation — are also expected to be seconded into community settings.
These multidisciplinary teams will be aligned with PCNs, based on neighbouring GP practices that work together. The networks will also have access to a new shared savings scheme tied to reductions in hospital activity, such as accident and emergency attendances, delayed discharge and avoidable outpatient visits and potentially medicines optimisation.
To engage with these joined up working systems, pharma must consider how its products can deliver cost savings across the whole care pathway, particularly in the shared savings scheme. This could involve helping the NHS to tackle problems such as overmedication through patient education or possibly reducing the need for outpatients’ appointments through remote monitoring devices. Pharma should also pay close attention to the findings of Getting It Right First Time (GIRFT) and the best practice case studies developed by NHS RightCare, since both of these initiatives focus on reducing unwarranted variation in quality and outcomes, which will be a key test of whether the plan is working.
Illness prevention and health inequalities
The plan acknowledges that ‘the social and economic environment in which we are born, grow up, live, work and age, as well as the decisions we make for ourselves and our families, collectively have a bigger impact on our health than healthcare alone’. The new integrated, multidisciplinary teams that are drawn from health, social care and the wider community, including the police and housing departments, will be key to tackling these variants in a co- ordinated and joined up way.
In particular, they will be looking at preventing illnesses and tackling the inequalities that can cause them, such as mental health problems, learning disabilities and homelessness. In line with this, the NHS and government want to look at funding key public health services from the NHS budget. Indeed, the Long Term Plan states that they will consider ‘whether there is a stronger role for the NHS in commissioning sexual health services, health visitors, and school nurses, and what best future commissioning arrangements might therefore be’.
Other related activity outlined in the plan includes the fact that this year local health systems will have to explain how they will specifically reduce inequalities over the next decade. Also, CCGs that receive a health inequalities adjustment will be, for the first time, obliged to show how they are targeting this funding ‘to improve the equity of access and outcomes’.
When thinking about the wider determinants of health, pharma needs to look at the bigger picture and consider where and how competition for money could come for illness prevention and management within ICSs – from improving damp housing conditions to education programmes in schools. Ideally, pharma needs to consider wrapping its value proposition around a service that adds real value to the NHS in this regard, rather than simply selling the product alone. Though it is important to realise that these integrated systems are varied in their state of development.
Budgeting
The plan states that the NHS will continue to support local approaches to blending health and social care budgets where councils and CCGs agree that this makes sense. The government will also set out further proposals for social care and health integration in a forthcoming Green Paper on adult social care.
Overall, the majority of funding will be population-based to make it easier to redesign care across providers, support the move to more preventive and anticipatory care models, and reduce transaction costs. Many contracts have already been moving away from Payment by Results (PbR) to block contracts with outcomes metrics, as they head towards capitated budgets and risk share.
Spotlight on key diseases
The plan also highlights the NHS’ aspirations to improve patient care for certain conditions, including cardiovascular disease (CVD), where a national CVD prevention audit is planned. The NHS also wants greater access to echo-cardiography in primary care and defibrillator networks. There will be a focus on anticoagulant medicines with a pharmacist and nurse programme too.
The NHS plans a range of measures to prevent type II diabetes and reduce variation in the quality of diabetes care. For example, newly diagnosed patients will be offered expanding provision of structured education and digital self-management support tools, including expanding access to the online self-management tool HeLP Diabetes. There is a strong emphasis on weight management within type II diabetes.
In respiratory disease, from 2019, the NHS will build on the existing NHS RightCare programme to reduce variation in the quality of spirometry testing across the country; PCNs will support the diagnosis of respiratory conditions, while more staff in primary care will be trained and accredited to provide the specialist input required to interpret results.
Over the next five years, Integrated Stroke Delivery Networks (ISDNs) involving all agencies, including ambulance services through to early supported discharge, will ensure that all stroke units meet the NHS seven-day standard for stroke care and National Clinical Guidelines for Stroke.
The plan also commits to dramatically improving cancer survival by 2028, by increasing the proportion of cancers diagnosed early from half to three quarters. Other aims include the development and implementation of networked care to improve outcomes for children and young people with cancer, simplifying pathways and transitions between services so every patient can access a specialist.
Digital innovation
According to the plan, all patients in England will have access to online consultations by 2022/23 and the ‘right’ to switch to ‘digital first’ GP practices. The only ‘digital first’ GP practice currently operating in the NHS is Babylon’s GP at Hand, which offers patients in London and surrounding areas free video consultations if they register with its practice based in Fulham.
However, in the plan, the NHS wants to ‘create a new framework for digital suppliers to offer their platform to primary care networks on standard NHS terms’. This indicates how disruptive technology is going to change patient pathways.
The plan also promotes a similar expansion of online consultations in secondary care to meet the ambition of avoiding a third of all hospital outpatient appointments within five years.
Conclusion
Many innovative ways of working — that were initially trialled by NHS Vanguards and are now being adopted by ICSs — provide the foundations for the plan, which sees integrated, population-based and preventative healthcare strategies as key to the future of the NHS.
The success of local NHS organisations in aligning themselves with the plan remains to be seen but with an imminent deadline imposed for all STPs to become ICSs, and a clear direction of travel on tackling health inequalities and embracing digital transformation, they will be under intense pressure to make radical changes.
To support local NHS organisations in managing transformation, pharma must align its proposition with the key principles that underpin the plan. For example, it must think more widely about illness prevention and management; ensure that its products are aligned with optimal care pathways and define how they can help to deliver whole system benefits.
Steve How and Oli Hudson are part of Wilmington Healthcare’s Consulting Team. For information on Wilmington Healthcare, visit www.wilmingtonhealthcare.com
