The NHS’ commitment to integrated, place-based care was reaffirmed in a recent white paper which positioned a new set of organisations, known as provider collaboratives, at the heart of delivering this change.
According to the Integrating care: Next steps to building strong and effective integrated care systems across England white paper, these groups of providers will take an ‘active and strong’ leadership role in ‘places.’
Indeed, provider collaboratives will be expected to agree and implement clinical pathways and service reconfiguration for a defined population, and challenge and hold each other to account on finance.
In this article, we explore what organisations provider collaboratives will comprise and how they will operate within the integrated care landscape. We also assess how they are likely to impact on prescribing and pathways.
Provider collaboratives
The white paper, published by NHS England and NHS Improvement (NHSE/I) a few months ago, highlights the importance of ‘place’, which is defined as a locale that has a population of 250,000 to 500,000 and is roughly coterminous with a local authority boundary.
It also underlines the role played by providers within ‘places’, where they are expected to assume responsibility for delegated budgets, with Integrated Care Systems (ICSs) only taking the lead where it is clear that work needs to be carried out over a larger footprint.
All NHS providers will be expected to join at least one of the provider collaboratives, which will be tasked with driving forward pathway changes and service improvements and making the NHS ‘financially and clinically sustainable.’
Each ‘place’ would typically have up to five hospital trusts, as well as ambulance, mental health and community care services, which are all expected to now form integrated structures.
Trusts that operate across a large area or are within a small Integrated Care System (ICS) are likely to want to be part of a collaborative that spans ‘multiple systems’, and NHSE/I is expected to set out guidance on how to do this soon.
The establishment of provider collaboratives will not be a totally smooth process, and some will struggle more than others to establish a new way of working together after nearly a quarter century of competition with each other.
However, the challenge of coping with the post-COVID backlog and having a thinly spread workforce and resources might force the process. Collaboratives will need to enact mutual aid arrangements such as collective waiting list management and look at their combined and individual spend to see how they can enhance productivity and improve value for money.
Hospital groups
In addition to providing guidance on vertical integration regarding the organisations that will encompass provider collaboratives, NHSE/I is also likely to issue guidance on horizontal integration – where hospitals of a similar size and role work with each other. While some horizontal integration, joint governance between certain trusts, and hospital group purchasing has been going on for some time, it is likely that this will be accelerated by the provider collaborative agenda.
Some hospitals have been told to form ‘hospital groups’ by NHS England – an initiative originally touted in the 2015 Five Year Forward View and modelled by the original acute care collaborative ‘vanguards’ in places such as Northumbria and Greater Manchester. Wolverhampton, Walsall, Dudley and Birmingham will form this type of group.
Decision-making units
Provider collaboratives are going to bring big changes to the stakeholder map for pharma companies that work with hospitals as decision-making units span the wider group rather than individual hospitals. NHS plans, Key Performance Indicators (KPIs), staffing and to an extent finance, will be based upon the collaborative rather than individual hospital trusts, and money will need to be spent according to population health needs within ‘places.’
However, prescribing decisions could well end up in the hands of the so-called ‘lead provider’ – a trust within a ‘place’ that will sign the contract with the regional NHS. In fact, taking on this function is one of the marks of a provider collaborative having gone ‘live’. It will, therefore, be important to identify the lead provider within each collaborative.
Changes in prescribing
Clinical Commissioning Groups (CCGs) are expected to be absorbed into ICSs or merge to the size of an ICS. These changes are likely to lead to a reduction in Area Prescribing Committees (APCs) where, for example, two or three CCGs that currently have separate APCs merge to fit the size of an ICS or are absorbed into the system.
While certain services, including some specialised commissioning, will go to ICSs, many CCG functions, in relation to formularies, medicines and decision-making, will be managed at place level by the provider collaboratives. So, rather than having individual drug and therapeutic committees, serving one hospital, possibly in collaboration with primary care, there will be a much wider focus on what should be used across the whole collaborative.
Consequently, territory and account planning, assumptions of who customers and payers are, and who controls rebates, and how area prescribing committees will operate, and on whose behalf, will all need to be reviewed in light of these changes.
New pathways
The place-based care model will undoubtedly give rise to new pathways and this will occur in two ways. Firstly, from a clinical perspective, there will be a focus on using the resources available within a place to change the model of care, as is being developed by the Getting It Right First Time (GIRFT) initiative.
Secondly, there will be changes in the geographical location of services. For example, some trusts within a collaborative may specialise in particular clinical areas, while there will also be some rationalisation of services within ‘places’ to drive efficiencies.
Reconfiguration may well involve closing or downgrading hospitals and moving more services out of secondary care and into the community as keeping patients out of hospital, where possible, is likely to be a key priority for many provider collaboratives in line with the NHS Long Term Plan.
The value proposition
Under the old financial system, individual trusts were paid for activity and they operated in competition with other providers. However, the new provider collaboratives will be working mainly on block or blended contracts with a focus on achieving outcomes that are built into those contracts.
In particular, they will be looking at population health – which requires equitable provision across the whole system – and also sustainability. So, there will be a much stronger focus on long-term benefits to both a ‘place’ and the wider system.
For pharma, this means thinking about the cost of a pathway within each trust and how a particular drug might impact on the system as a whole by, for example, keeping patients out of hospital and enabling homecare. So, the ability to map pathways at system level and look at costs for each part of the system, using real-world data, will be particularly important.
As the NHS continues its transition to integrated, population-based care, ‘places’ will form the locus of local decision-making under the management of the new provider collaboratives, which will drive service improvements and pathway changes, while ICSs take on a wider strategic commissioning role.
These developments are going to have a big impact on pharma from new customers and payers, to changes in prescribing and the introduction of new patient pathways. This, in turn, will impact on pharma’s value proposition, which must take account of population health principles.
In line with this, it is essential for industry to think widely about illness prevention and management, to ensure that its products are aligned with optimal care pathways and to define how they can help to deliver whole system benefits in line with key NHS priorities.
Evidence-based propositions that, for example, identify unmet needs within specific patient populations and support the recovery of non-COVID services will be invaluable for provider collaboratives as they are tasked with uniting different service providers and delivering change amid the legacy of the pandemic.
