Annual influenza vaccinations will be offered to all children aged two to 17 in the UK from 2014.

A nasal spray of the Fluenz vaccine will be used rather than an injectable form, except with children in high-risk groups.

The vaccination programme – the first of its kind in the world – is predicted to save 2,000 lives per year given only moderate uptake (30%).

As well as saving many children’s lives it could protect non-vaccinated people, especially elderly family members, through the ‘herd immunity’ effect.

The Joint Committee on Vaccination and Immunisation (JCVI) said the vaccine would be offered to nine million children in the UK, more than doubling the number of vaccinations available.

According to the Chief Medical Officer for England, Professor Dame Sally Davies, if only 30% of these children receive the vaccine there will be 11,000 fewer hospital admissions and 2,000 fewer deaths.

The vaccination will be optional and will depend primarily on GP surgeries, as there are too few school nurses to deliver the programme.

AstraZeneca’s Fluenz is a live attenuated vaccine sold in the US as FluMist. The UK contract could be worth £100m a year to the company.

Vaccinating children could also protect vulnerable family members, including babies and the elderly – an effect known as ‘herd immunity’.

Lancashire’s health and wellbeing board has identified four main priorities to improve the quality of care for local residents, board papers have revealed.

Improving the quality of services for mothers and young children, people with mental health issues, long-term conditions and for the elderly were all identified in its draft strategy.

The document said the purpose of the strategy was to “achieve shifts in the way that partners work”, which the board hopes will create a “greater impact on the health and wellbeing” in the region.

Priorities were identified by the board after analysing data and intelligence available through the Joint Strategic Needs Assessment.

The board aims to provide “accessible and effective support and services” to expectant mothers and their families and to “promote and safeguard” the health and wellbeing of children in pre-school.

Promoting emotional health and wellbeing in children and adults and supporting local residents who are affected by mental health problems to play a “full and active role in society” has also been identified.

The board hopes to reduce the incidence of, and mortality from, long-term conditions in the region, as well as improving the quality of life for people with long-term issues and their carers.

Finally, the board aims to increase life expectancy at 65, whilst supporting “older people and their carers” to play a role in local society.

A host of ‘early win interventions’ were also listed within the strategy. These include identifying people at risk of admission into hospital and providing intervention and support for carers of those with dementia.

The Government has published an ‘implementation framework’ for its mental health strategy, involving a wide range of care services.

A ‘mental health dashboard’, allowing progress against the relevant objectives for the NHS, social care and public health to be measured, will be published in the autumn.

The framework’s core principle, and a priority for the NHS Commissioning Board, is “parity of esteem” between mental and physical healthcare.

Other priorities include giving more people access to evidence-based treatments; ensuring that patients and their families and carers are involved in service design and delivery.

The integration of mental with physical healthcare is reflected in the dual priority of improving the physical health of people with mental illness and the mental health of people with physical illness.

The framework outlines steps that commissioners and service providers, as well as business and the community, can take to improve the prevention and treatment of mental illness.

The CCG authorisation process will require applicants to prove they have the capability “to commission improved outcomes in mental health”. CCGs are urged to appoint a mental health lead at senior level, use specialist support and guidance, focus on early intervention and on recovery, and develop “innovative service models”.

Providers of mental health services should “focus on choice, recovery and personalisation”, as well as the relationship between physical and mental health.

GPs are asked to provide “appropriate early interventions”; to recognise and treat “co-morbidity of physical and mental illness”; to provide a choice of treatment for mental illness; and to develop “good practice in care planning”.

Guidelines for local authorities, health and wellbeing boards, social and public health services, Local Healthwatch and employers are included.

Support for these improvements at a national level will be provided by the NHS Commissioning Board, and by the development of a tariff for mental health services that will “connect payment to recovery and to the patient’s experience”.

NICE has published the first clinical guideline on how healthcare professionals should care for those aged under 19 who have spasticity.

Guidelines recommend referring patients to specialists without delay and considering continuous pump-administered intrathecal baclofen to tackle pain or muscle spasms.

The advice will improve the “mobility and comfort” of patients who have stiff muscles caused by neurological disorders, NICE said.

Around 24,000 people under the age of 19 are believed to have the condition in England and Wales. It is associated with non-progressive brain disorders, such as cerebral palsy.

Healthcare professionals are also advised to offer a management programme to patients that is individualised and goal-focused. Assistance to patients, parents and carers to develop and implement such programmes is also advised within the guideline.

Also, doctors are encouraged to perform the spinal operation selective dorsal rhizotomy in those whose condition causes them limited mobility.

Professor Mark Baker, Director of the Centre for Clinical Practice at NICE, hopes the new recommendations provide “greater comfort and independence” to youngsters with the condition.

Will the new NHS deliver effective community-based healthcare or revert to the old fire-fighting approach? Maxine Vaccine asks whether a cheaper healthcare model is something the NHS can afford.

Healthcare in the community is an idea whose time has come. It’s not new, of course: preventative care and avoidance of hospital admissions were strong themes in the Darzi review. For years, the NHS has been talking about a radical change in the healthcare model: from acute to chronic, from fire-fighting to safer housekeeping.

What the new austerity has done is to impose a financial imperative on the change. The general principle that prevention is cheaper than cure has to be hard-wired into patient pathways that deliver measurable cost savings. That may work readily for a condition such as COPD where the clinical and financial stakes are high – but does it work every time for obesity, for diabetes, for depression? The problem with mixing austerity and community healthcare is that you need to pay up front for primary care, for prevention, for monitoring and control, and the savings appear further down the line. Which is not the way business tends to work.

The Government has taken some positive steps towards integrated care. The decision to allow physiotherapists and podiatrists to prescribe independently may seem a minor step, but it’s unprecedented (not just here, but worldwide) and it bridges the gap between primary and secondary care, giving the outpatient clinic a decisive power of intervention that addresses a key weakness in long-term condition care.

On the other hand, the worrying prevarication over the Dilnot recommendations highlights concern that shifting responsibility for public health to local government is merely a way for the coalition to go on claiming it’s not cutting the NHS budget – when it is, of course, slashing the local government budget to ribbons, and social care is bearing the brunt of that. Our hospitals are increasingly packed with ‘revolving door’ patients who, until recently, would have been cared for by social services: alcoholics, drug addicts, the mentally ill, the disabled, the elderly.

So the wheels are in danger of coming off the Government’s model of community-based care. Even GP-led commissioning – this Government’s flagship health concept – may ultimately be disabled by austerity culture. There’s a growing sense that CCGs exist to cut costs, not to improve care – and GPs don’t have the time or the stomach for that. If the balance between clinical and financial outcomes tilts too far towards the £ side then CCG management will be outsourced, and the circle of private providers and private commissioners will be complete.

But whether it fully works or not, community-based healthcare is what the realities of patient need dictate. Whether you’re looking at mental health, diabetes, obesity, sexual health or the effects of smoking, the message is clear: the NHS needs affordable strategies to keep people well, keep them out of hospital and, where possible, keep them looking after themselves.

Integrated care means not just the integration of health and social care, but that of primary and secondary care, and that of different therapies. Pharmaceutical companies need to see drug interventions as part of a multi-faceted patient pathway in real time. They need to see diagnostic and device companies, physiotherapy and psychotherapy providers, as partners rather than as rivals. In hard times, nothing of value should be wasted.

Making the best of what’s available by combining talents and resources is the future of the NHS. It needs to be the future of the life science industries as well.

Maxine’s views are not necessarily those of Pharmaceutical Field.

NICE has recommended Bayer Healthcare’s convenient Xarelto (rivaroxaban) in final guidance as a treatment option for adults with acute deep vein thrombosis (DVT).

The positive recommendation sees Xarelto become the first non-VKA oral anticoagulant to be recommended for use on the NHS after it impressed in phase III clinical trials.

Professor Carole Longson, NICE Health Technology Evaluation Centre Director, said the treatment is “a potential benefit for many people who have DVT”.

It is estimated there will be more than 46,000 cases of acute DVT in England and Wales this year, with that figure rising to 50,000 within the next four years.

Xarelto is orally administered, enabling patients to avoid the process of regular monitoring through blood tests, dosage adjustments and concerns over diets due to the existing treatment’s interaction with certain food groups.

Dr Gerry Dolan, Consultant Haematologist, Department of Haematology, Nottingham University Hospital, said the guidance provides patients with “an important new therapy choice”.

He added: “Xarelto is proven as an effective agent for DVT treatment which removes some of the challenging constraints of current standard therapy, and can help re-shape and improve anticoagulation services by reducing our reliance on regular coagulation monitoring.”

What priorities does Andrew Lansley’s draft mandate for the NHS Commissioning Board reveal?

The draft mandate for the NHS Commissioning Board (NHSCB), published on 5 July 2012, is a manifesto for the new NHS: the first clear public statement of the anticipated course of NHS reform since the Health and Social Care Act became law. It offers a snapshot of the emerging structure for local commissioning, and highlights the Government’s key priorities for an NHS reform that is now a reality.

Introducing Our NHS Care Objectives: A Draft Mandate to the NHS Commissioning Board to Parliament, Health Secretary Andrew Lansley said: “Today we will be laying the foundations of the new, more independent NHS.” By this, he explained, he meant an NHS “free from constant political interference” and “tasked with continuously improving the care that patients receive”.

Transfer of powers
A key background document to the draft mandate is Lansley’s letter to the new Chair of the NHS Commissioning Board Authority, Malcolm Grant, in April. The letter stated his primary objective as being
“to design the Board so it transfers power to local organisations”. Other priorities included integrating health and social care and promoting patient choice.

Another important background document is the NHS Outcomes Framework, published in December 2010 and updated a year later. This defines the patient outcomes the NHS has to work towards – a counterpart to the business processes defined by the reform agenda.

The draft mandate has been issued for consultation. The final NHSCB mandate will be published in October and will guide the Board when it assumes its full statutory authority in April 2013.

Improving healthcare outcomes
The draft mandate begins by setting the context: the NHS is facing “one of the tightest funding settlements in its history”, while elderly care, long-term conditions and mental health are growing priorities. It outlines 22 objectives for the NHSCB for the two years from April 2013, as well as ‘ambitions’ for the coming decade.

The first major section lists 11 objectives for improving outcomes. The first six relate to the NHS Outcomes Framework – one for each of the five domains and one for the whole – setting concrete targets in QALY and similar terms, but leaving the actual numbers to the final version.

While there are no objectives for specific conditions, this section refers to dementia and mental illness and notes the need for better integration of general healthcare with treatment of these conditions. The NHS should work towards treating mental health as “on a par with physical health,” it states. There are objectives for reducing health inequalities, including life expectancy at birth. However, the reference to “greater improvement in more disadvantaged communities” should be seen in the context of the planned shift of public health funding from the NHS to local government. Finally, there are objectives relating to service performance standards and support for patient self-care.

Patient choice and local control
While the first 11 outcomes are related to the agenda for NHS improvement defined by Lord Darzi in 2008, the last 11 belong wholly to the new reform agenda. One crucial objective relates to patient choice. The Board must ensure that people are “involved in decisions about their care and treatment”; that personal health budgets are available “to anyone who might benefit”; and that a patient who has waited 18 weeks for treatment is entitled to choose another provider.

The Board is required to develop integrated care through joint commissioning and other methods, particularly for “people with dementia or other complex long-term needs”. It should also improve the quality of NHS information, using IT to make the NHS “transparent” to patients and carers.

The Government’s innovation agenda is highlighted by an objective requiring the Board to “promote access to clinically appropriate drugs and technologies recommended by NICE”, as well as supporting the participation of NHS clinicians and patients in life science research.

The section on commissioning states that the Board should fully authorise “as many CCGs as are willing and able” by April 2013, and allow the CCGs “full control over where they source their commissioning support”. The new clinical senates and networks will provide advice, with CCGs “free to make their own arrangements”.

The Board must have a “transparent, principle-based system” for managing “poor performance” or “financial risk” by CCGs. It must “support a fair playing field between providers” and “ensure that financial incentives for commissioners and providers support better outcomes and value for money”. The latter objective includes the controversial Quality Premium, a bonus payment rewarding CCGs who achieve a surplus on their annual budget. This will be funded from within “the overall administration costs” available to CCGs.

Crucially for industry, there is an objective to support “changes in services that lead to improved outcomes for patients”. These must meet four criteria: support from clinical commissioners; strong patient engagement; a clear clinical evidence base; and consistency with patient choice.

On the critical issue of cost savings, the mandate says only that the Board must ensure that QIPP savings are made “in a sustainable manner” as dictated by the Treasury, but without reducing service quality.

Between the lines
Responses to the draft mandate have focused on its open-ended nature. Mike Farrar, Chief Executive of the NHS Confederation, commented: “Unlike documents that have gone before it, the mandate does not seek to develop an ever-growing ‘wish list’ of objectives. It rightly encourages commissioners to exercise their knowledge of the needs of their local communities to plan and deliver the best care.”

Shadow Health Secretary Andy Burnham argued that Lansley had missed an important opportunity to highlight the issue of healthcare rationing – which the Health Secretary had recently stated to be
“unacceptable”. The delegation of control to local commissioners, Burnham argued, was “a mandate for privatisation.”

Dr Richard Vautrey, Deputy Chairman of the BMA’s GP Committee, praised the mandate for not placing too many restrictions on GP-led commissioning. However, he was strongly critical of the Quality Premium, which he claimed would encourage rationing and increase health inequalities.

Whatever the consultation period delivers, the draft mandate for the NHSCB is a clear statement of the NHS reform agenda: to deliver improved patient outcomes through CCG autonomy and provider competition.

What does the ‘single operating model’ for primary care commissioning mean for GPs?

The NHS Commissioning Board Authority’s ‘single operating model’ for primary care commissioning represents a major step in defining the relationship between GPs and the new NHS. As such, it is essential reading for anyone with a stake in prescribing behaviours and, more widely, in patient pathways.

A major question posed by the Lansley reforms is: who should commission the commissioners? If GP-led groups are responsible for commissioning secondary care, who can commission primary care? The answer, the NHS Commissioning Board, was greeted with mistrust by many GPs who asked why they needed some Big Brother watching over the job they had always done.

In addition, the passage of the Health and Social Care Act left a lot of broken glass scattered through primary care. The relationship between clinical outcomes and money, the involvement of the private sector in the NHS and the apparent fragmentation of the health service are issues that divided
the GP profession.

So the single operating model has the task not only of outlining new clinical and business relationships, but of building professional bridges. The Board tackles this challenge by saying up front that it seeks to
achieve “the right balance between national consistency and local decision making”.

Unlike earlier documents describing the infrastructure of the new NHS, Securing excellence in commissioning primary care does not list concrete developments to be in place by April 2013. Rather, it outlines a pattern of relationships that will develop from that date, when the new single operating model
for primary care commissioning becomes operative. It represents the parts of the new
NHS working together with a clear goal of outcome improvement.

The commissioning challenge
According to Dame Barbara Hakin, National Director for Commissioning Development, the new system aims to “tackle unwarranted variation and take positive steps towards raising the overall standard of primary care”. The document notes that primary care, while accounting for only 15% of the NHS budget, has a
profound role in making “preventative interventions” and influencing all the care patients receive.

The challenge of replacing “many different systems” for primary care commissioning with “a single national
operating model” without losing “vital local responsiveness”, the Board says, depends on “establishing relationships and arrangements across the new organisations” – including CCGs, whose health strategies
will set the context for primary care.

The NHSCB will be responsible for planning, securing and monitoring primary care services. Its local area teams will manage the performance of GPs and other primary care providers (dentists, community pharmacists and opticians), and will help to support providers in difficulty and deal with major emergencies.

The local area teams will support patient “choice and control in designing services that respond to their needs”, focusing on “the basic service offer” (such as early diagnosis) to reduce variations and health inequalities. Likewise, they will support the development of “local area clinical leadership teams” that draw on the expertise of all types of primary care clinicians. Finally, their focus on patient outcomes means they will look for “improvement strategies” at all times.

All together now
Most primary care commissioning will take place through the Board’s local area teams working with CCGs, local authorities and health and wellbeing boards. The Board as a central authority will “ensure consistency” and provide the framework for performance management and quality assurance. Crucially, this system involves “fewer managerial resources” and “larger geographical footprints” than the previous system. It does not remove local initiative: it just removes the SHA and PCT management layer.

At the heart of the model are the common operating procedures for local area teams, of which the most important is “to standardise the performance management frameworks and processes at practice, provider and individual levels”. Managing variability and the healthcare market are also key priorities.

Commissioning support services may also assist local area teams: emphasis is placed on the value of
business intelligence in providing “a single flow of standardised information”, and the potential for CCGs to share support for primary care development and redesign with local area teams.

Micro commissioning
CCGs themselves will work closely with the NHSCB to review the “micro commissioning decisions” made by
GPs in “each referral and prescription”. The Board says that its work with CCGs has shown they can progress effectively together towards “quality improvement” through benchmarking, data sharing and peer review. It notes further that CCGs will be able to commission integrated “wrap-around” community-based services in which GP practices can participate, with care taken to manage conflicts of interest.

The local area teams will establish relationships with a range of partners, including CCGs, Local Healthwatch, health and wellbeing boards, local authorities, Public Health England local units and the CQC. Clinical networks will feed into the primary care system “with a particular focus on early diagnosis and timely treatment”. Public health commissioners will advise local area teams on priorities for the local
population, and work with them to develop health improvement initiatives that may include primary care.

The Board concludes: “During the next three to six months, we will fully explore all the interdependent relationships critical for the operating model and take any action necessary to ensure that they will work effectively.” It encourages discussion of the model within PCT clusters and feedback on
potential improvements.

A business network
The single operating model for primary care commissioning is not so much a ‘one size fits all’ as an ‘all things to all people’. It shows the old hierarchical NHS giving way to something much closer to a business network, with shared rules and goals but different cultures. The imprecision of the arrangements described displays the will to promote clinical innovation and business
development.

The emerging structure is designed to give GPs more confidence that they will be neither isolated nor controlled. Those who need guidance and support will receive it, while others will have the freedom to change treatment pathways and business models. This will help to defuse opposition to reform in the
profession, while setting the stage for further changes.

For pharma, the new model points to the development of a complex and flexible customer network with many points of contact. Key account managers are much concerned with how primary care operates and the factors influencing it. This model shows primary care in a dynamic field of NHS and other stakeholders, responding to ideas from all sides: an exciting prospect for suppliers.