How does the NHS Operating Framework influence pharma’s engagement with the NHS?

Economics continues to dominate the healthcare headlines. There has been much conjecture in recent weeks about NHS spending and how crucial promises of a ‘ring-fenced’ NHS budget appear to have been broken. Treasury statistics show that frontline spending on the NHS has increased by £3.4 billion since last year. But opponents claim the £1.6 billion surplus reported by PCTs and SHAs in 2011/12 has not been ploughed back into the health service – breaking David Nicholson’s 2010 vow that ‘every penny’ saved by the NHS would be reinvested in patient care. The DH says the surplus is being made available in the 2012/13 budget. With the NHS facing up to the realities of the ‘Nicholson Challenge’, the political debate over healthcare spending will run and run.

Operating Framework

The latest NHS Operating Framework clearly outlines the spending plans for 2012/13. It confirms that SHA/PCT surpluses will continue to be made available during 2012/13 and final year-end surpluses will be carried forward to the NHS Commissioning Board in 2013/14. PCT surpluses are expected to be made available to the relevant local health systems in future years. Conversely, PCTs carrying a legacy debt will be required to clear it during the year. Incoming CCGs will not be responsible for PCT legacy debt but they are expected to work closely together to ensure the situation does not arise.

PCT recurrent allocations will grow by at least 2.5% in 2012/13. PCTs are required to set aside 2% of their recurrent funding for non-recurrent expenditure. SHA clusters will hold these funds, with PCTs required to submit business cases to access them. The cost of organisational change during 2012/13 will need to be met from the 2%.

Tariffs and incentives

The framework outlines developments to the payment system in 2013, to incentivise the realisation of QIPP efficiencies and drive the quality and integration of services. Payment by Results has been expanded to encourage best clinical practice and better patient outcomes. Best practice tariffs are extended to:

• Incentivise more procedures being performed in a less acute setting
• Incentivise same-day emergency treatments where appropriate
• Increase the payment differential between standard and best practice care for fragility hip fracture and stroke
• Promote the use of interventional radiology procedures

Quality improvements are also incentivised in areas such as adult mental health, chemotherapy delivery, HIV services, podiatry, trauma, maternity care and paediatric diabetes. CQUIN is also being developed to provide a stronger incentive to deliver QIPP objectives. The amount providers will be able to earn for incremental quality increases above the standard contract will rise to 2.5% – across all standard contracts. Existing national goals for VTE risk assessment and responsiveness to the personal needs of patients will remain. In addition, two new national goals are introduced:

• Improving diagnosis of dementia in hospitals
• Incentivising the use of the NHS Safety Thermometer

Planning and accountability

The final chapter of the Operating Framework outlines the accountability arrangements for the final year of transition to the newly structured NHS. In 2012/13, the DH will continue to work through SHA clusters to hold PCT clusters to account – handing the baton for accountability over to the NHS Commissioning Board in April 2013. The framework warns that NHS organisations must improve the quality of services provided through the year, while delivering transformational change and maintaining financial stability – with under-performance likely to include ‘intervention from the centre.’
In 2012/13, the key accountability arrangements are:

• The current statutory framework – where SHAs and PCTs remain the statutory units of accountability
• The NHS Constitution – securing patient and staff rights
• Contracts between commissioners and providers
• CQC – regulating NHS providers
• Monitor – ensuring Foundation Trusts are meeting their terms of authorisation and delivering against priorities

Transition plans

The transition to the newly structured NHS is a dominant theme throughout the 2012/13 Operating Framework, and measures to plan for it within the current accountability arrangements are clearly articulated. In fact, given the ambitious nature and close proximity of the reorganisation, details around the planning arrangements for the final year of transition are surprisingly brief.

‘As the industry waits for clarification of individual CCG plans, broader strategies designed at PCT cluster level are already available.’

According to the framework, PCT clusters are each required to develop an integrated plan for the period 2012/13 to 2014/15. The plan should have a clear focus on quality and the national priorities outlined in the Operating Framework. The narrative should be supported by ‘data trajectories for each PCT’, and bring together elements around QIPP, finance, activity, workforce, informatics and transition to the new structure.

Shadow CCGs must support the plan, so they have a strong base on which they can develop their own planning for 2013/14. Likewise, the integrated plans need to reflect the outcomes of local Joint Strategic Needs Assessments. As with the NHS Outcomes Framework, emphasis is placed on integrating all care sectors – with PCT clusters urged to ensure that the public health transition elements of their plan are supported by local authorities.

Implications for pharma

The Framework stated that all PCT clusters’ integrated plans needed to be prepared – and approved by SHA clusters and the DH – by the end of March 2012. These plans are of major importance to pharma. They will contain vital information on the priorities, population needs and long-term ambitions of local health organisations. With the four-wave process to authorise 212 CCGs in England well under way, further data on the specific needs of individual local health organisations will emerge in the coming months. The requirement to publish Commissioning Intentions, updated JSNA and a whole variety of other forward-looking documentation as part of the authorisation phase promises to provide pharma with a comprehensive view of its market environment at the local level. But as the industry waits for detailed clarification of individual CCG plans, broader strategies designed at PCT cluster level are already available.

At a time when finances across the NHS are being squeezed yet the bar for quality and clinical outcomes is being raised, insight into the challenges facing key customers is a valuable commodity for medical sales professionals. The transition of the NHS to a new structure can be a catalyst for proactive medical sales professionals to improve their environmental monitoring, and significantly develop their understanding of customer need. The challenge for the industry is to ensure that key account managers speak in the same language – the same currency – as the customers with whom they seek to engage. The nature and scope of that currency is defined in national documentation such as the NHS Operating Framework and NHS Outcomes Framework, and within the vast local plans that are emerging as the NHS transition gathers pace. And well beyond it.

Success is about finding a common currency with your customers. The clues are out there.

University Hospitals of Morecombe Bay NHS Trust (UHMBT) has lodged an official appeal against proposals to move specialist vascular services away from the Royal Lancaster Infirmary (RLI).

The NHS Lancashire and NHS Cumbria boards have backed proposals to create one clinical network across the two regions supported by three specialist vascular intervention facilities.

These have been recommended at the Royal Blackburn and Royal Preston hospitals, with another at Cumberland Infirmary in Carlisle.

But Eric Morton, interim Chief Executive for UHMBT, said its unit has “evolved” over the 40 years it has been open and “we want this to continue”.

Under the proposals, routine and planned vascular treatment would be provided for patients at local hospitals, as well as all outpatient and day case surgery.

But all specialist inpatient care would be moved to one of the new facilities before patients are discharged or transferred to their local hospital for rehabilitation.

“It is well-recognised by vascular experts that, where such services treat high numbers of patients, the services are safer and the resulting clinical outcomes for patients are better,” said Dr Jim Gardner, Medical Director for NHS Lancashire.

“There is considerable evidence and professional backing to support the creation of the vascular network, and the three specialist vascular intervention centres. We know that the creation of these centres will result in more effective and safer services, and most importantly better patient outcomes.”

A final decision on the proposals will be made by the North of England NHS Specialist Commissioning Board and the NHS Commissioning Board later this year.

Undiagnosed or untreated chronic kidney disease (CKD) causes 45,000 premature deaths in England each year, according to a new report.

The study, commissioned by NHS Kidney Care, estimates that CKD costs the NHS £1.4bn per year – about half of which is spent on treating advanced CKD with dialysis or transplants.

Earlier diagnosis and intervention to address the condition – through behaviour changes and drug therapies – could prevent many severe cases and save many lives, the study concludes.

CKD is a progressive condition in which the kidneys become less effective at cleaning the blood, increasing the risk of cardiovascular events.

According to the report, 1.8m people in England have been diagnosed with CKD and another 1m may be undiagnosed.

“Chronic kidney disease has a much greater impact on people's lives, and on NHS costs, than is generally recognised,” said study author Marion Kerr.

“Most of the spending on CKD is for people with advanced disease. We hope this report will focus attention on the need for early detection and intervention.”

Dr Donal O’Donoghue, National Clinical Director for NHS Kidney Care, commented: “Putting the cost of care aside, for individuals the late identification of kidney disease means delays in diagnosis with a failure to manage risk factors including heart attacks, strokes and progressive kidney disease.”

The General Practitioners Committee (GPC) has questioned the move to create a composite indicator for diabetes believing it may have an adverse affect on patient care.

Measures to conduct nine separate checks in each diabetes patient will demotivate doctors, lead to increased referral rates and infringe on rights to refuse treatment, the GPC warns.

Dr Laurence Buckman, GPC chair, said in a letter to NHS Medical Director Sir Bruce Keogh that a single indicator may lead to “unintended consequences”.

The Department of Health recently asked NICE to consider a composite indicator for inclusion in the Quality Outcomes Framework (QOF) after an investigation found only half of patients received the nine existing separate checks.

But the GPC argues that if the new indicator were to be introduced it would “have consequences”, especially where patients did not wish to engage in specific checks or attend altogether.

“A composite indicator that defunded practices of the whole quantum of diabetic QOF funding – designed to fund the process, not just the outcomes – risks demotivating practices completely and would almost certainly have the unintended consequence of increasing diabetic referrals,” said Dr Buckman.

He added that a “regimented tick-box check” would be “extremely counterproductive”.

But Sir Bruce responded by defending the switch. “The QOF is currently not incentivising practices to increase the number of their patients who receive all nine care processes that are the hallmark of good diabetic care delivered to patients,” he said. “If one or two are missed, patients are not getting the care they should receive.”

Proposals to cut hospital services in Worcestershire mean communities are facing a choice of which district hospital to lose.

Worcestershire Acute NHS Trust (WAHT) has offered six alternative scenarios to cut £50m from the combined budgets of three hospitals.

Plans to focus A&E and maternity services in Worcester, closing down those hospital departments in Redditch and/or Kidderminster, are thought likely to become reality by 2015.

Worcestershire county councillor Fran Oborski branded the trust’s consultation exercise an “irresponsible” attempt to lead local authorities into conflict.

Dr Richard Taylor, formerly elected Independent MP for Wyre Forest as the representative of a campaign to save Kidderminster Hospital – said there was a danger that the county could “gang up” on Kidderminster.

The Alexandra Hospital in Redditch, which also serves Bromsgrove, Alvechurch and surrounding areas, is facing either partial or total closure.

A local campaign with cross-party town council support brought 150,000 people onto the streets to defend the town’s A&E and maternity services.

The A&E admission figure for Redditch is 34,856 people per 100,000, compared to the county average of 27,911.

Local people in emergencies would face a hour-long journey to Worcester Royal Hospital, campaigners said, with mortality from strokes and heart attacks being made far more likely.

“The whole council remains fully committed to supporting the Save the Alex campaign,” commented Councillor Bill Hartnett. “We must do all we can to protect the future of the Alex and to maintain the essential A&E and maternity services it provides to the whole community.”

WAHT plans to launch a three-month public consultation in November.

The NHS Confederation has called for greater levels of transparency in order to stop patients taking cash-strapped trusts to court over prescribing decisions.

David Stout, NHS Confed Chief Executive, said trusts need to be honest about the financial challenges they are facing to help patients understand why certain treatments approved by NICE are not prescribed.

He was responding to comments made by NICE chair Sir Michael Rawlins who claimed that patients should take trusts to court if they were being denied recommended medicines.

Mr Stout agreed that trusts should be providing treatments to patients they are “legally entitled to”. But he added that “every NHS organisation has a finite amount of money available” and that funding for new treatments means “fewer resources for other treatments”.

“NHS organisations are faced with the difficult challenge of achieving the best outcomes and highest quality care for patients while balancing their budgets,” he said.

“The issue raised by Sir Michael Rawlins leads us on to the wider debate that we need to have about the fact that the NHS is facing an unprecedented financial challenge. All NHS organisations are facing budgetary pressures while striving to maintain high quality care.

“We need to be open and honest with the public about what the consequences of this financial challenge are, and the fact that trade-offs will be required if we are to improve standards of care while keeping the NHS affordable.”