As widespread changes from the NHS implementation begin to take shape, all eyes are turning towards the new plans for GP commissioning and GP consortia prescribing formularies. Omar Ali evaluates the changes and reviews the impact for both the NHS and pharma.
Access to medicines has wide reaching implications to every aspect of healthcare ranging from individual doctor-patient interventions, through to strategic shared care formularies across healthcare economies. However, as medicine access has far reaching tentacles entwining government policies, patient support groups and the pharmaceutical industry, any process to bring a change to the current status quo will be a challenging task. Bring forth The Coalition: our programme for government, an NHS document from the Secretary of State for Health whereby the introduction of GP Commissioning on outcomes and the creation of new GPC prescribing formularies is already underway.
The deficit and transitional mindset
The NHS already has its past – and the vision for the future is taking shape. But as with most things in life, it’s the transitional state of flux which is most painful. And this painful process will take some time. In years gone by, the NHS has seen budgets increase from £40billion to over £112 billion last year. The coalition has stated clearly, growth stops now. Growth this year was a miniscule 0.1%. It’s a flat line.
It is this flat line that is causing all the consternation around the £20 billion deficiency to come in the next seven years – this does not take into account the current deficit, which all PCTs need to settle prior to being extinguished. Whilst we can plan for future deficits and can do nothing about the past history, what the NHS is doing right here, right now, is having a direct impact on healthcare, associated providers, commissioning organisations, and of course the pharmaceutical industry.
When you next see someone from the PCT about why a drug isn’t funded – please don’t fall for the QIPP line, much abused terminology – remember this mindset. The PCTs have been combined into large regional clusters now – another process by which many jobs are ‘released/lost/liberated’, depending on your viewpoint. But what of the PCTs’ functionality when its days are numbered? Well, it goes like this: switch off the electricity, disconnect the gas, turn out the lights and vacate the premises – and don’t forget to settle the bills before you leave…
It’s a tough ask, but not an alien mindset. Settle all bills, leave everything as you found it, vacate the premises. I want to concentrate on this mindset. Firstly, it’s going to be difficult to think ahead about commissioning plans, medium term intentions and future funding when you’re not planning to be in the neighbourhood as such – or if you are, under a different role/guise/business solution. It’s probably quite easy and functional to get into ‘bailiff’ mode – sell assets, throw out excess junk, and remember, don’t forget to settle the bills. It is exactly this ‘interim’ phase of NHS reform that pharma is struggling with – no wonder your drug is not funded! No wonder medium term investment is often missing. No wonder QIPP is misaligned for simple ‘saving money’ as opposed to ‘self-funding innovative interventions’.
GP consortia will not inherit the current deficit of the PCTs/SHAs before they disappear – remember they will have their own £20 billion deficit to handle in less than seven years due to flat-line funding. Growth of NHS costs is, and will, continue to grow as it has done. Just because the coalition has stated flat-line funding it doesn’t mean patients/clinicians/interventions/pace-of-technology will change. It will continue, it’s just not matched by funding.
PCTs are desperately trying to ‘settle their bills’ before they vacate the premises. This will of course lead to some rash decisions, serious financial cuts and restricted investments. It must also be hard to keep delivering savings when you know that the gratitude at the end of it is probably ‘your job no longer exists, in fact, neither the does the PCT’. That probably explains why so many have left or are planning on leaving. It’s a thankless job with a thankless future. In fact, at least a quarter of my good NHS medicines management contacts have left their roles – which makes decision making on current PCT formularies even slower. But where have they all gone?
The new tenants
Current PCT medicines management (MM) teams can see what’s coming and, although some individuals do have their heads firmly in the sand, many are defining future roles and interpreting new models of medicines management and how GP consortia formularies will work. There’s basically four models of what medicines management will look like; but it’s crucial to understand how current medicines management model is funded.
The current model
We have more than 20 members within the medicines management team at our PCT. The funding required for this team’s salaries, wages, pensions, holidays and sick leave is more than £1 million per annum. The money is top-sliced further back at a SHA level – so it’s never really viewed as a cost at any level below this. The team are ‘just there’ – and they carry out the functions – as those in the industry have come to learn and love so well! Now, with SHAs & PCTs dissolving, this top-sliced money gets redirected back to the GPs.
Now they have the funds and decide what to do with it they will essentially become MM teams of the future. The issue is really on a day-to-day basis. The GPs would see various elements of what the MM team would do and they could take it or leave it to a certain extent. When you are not directly paying for something it’s easy to be keen, indifferent or against. So teams were often invited, and often unwelcomed, into GP premises to give prescribing advice which was either followed, obeyed or ignored. We were viewed as ‘reps for the government’ in a way. With prescribing plans and ideas that were ‘dislocated from the work that GPs do on a day-to-day basis’. Well, all that is about to change. Why? Because GPs will now pay for medicines management advice – and how they commission it will have a dramatic effect on how pharma interacts with the new GP consortia and the formularies they create.
The future model
There are four separate models of medicines management provider solutions that have emerged and are in play. It is critical for you to know about how these shape up in your territories – they will form the basis of the future relationships and in-roads to the new GPC prescribing formularies.
Why not just continue and not change? It’s not an option. Remember the £1 million that has been top-sliced by the SHA to pay for the MM team? Well the SHA/PCT are disappearing – and so with it does the £1million budget. So all around the country, MM teams need to devise a future model action plan for survival and they need it fast.
Model a: pharmacist/GP and the NHS ‘speed date’
Pharmacist(s) who are in well serving relationships and project interactions split away from the PCT/MM team and secure salary/funding with a GPC/or set of practices within the GPC. Trust me, GPCs don’t really understand what we do, so their idea of what we are worth, and my idea of what I am worth is fairly polarised. But they have the money and so proving this is firmly in my court. As an interim phase, some PCTs have ‘hived off’ their MM teams in an effort to assist the ‘speed date’ process. It’s kind of ‘here, check out these guys, fancy some of this?’ type discussion. To which the answer could be yes, no, or I will consider some other options.
Model b: pharmacy MM team forms a social enterprise
It rings of NHS and feels like NHS. All transactional profits are invested back into the system to pay for the services and projects carried out by MM teams. It’s an interesting notion and could be less appealing for those keen on starting enterprising ventures. But funds can come from a variety of sources including sponsors and the government when you are a social enterprise. Furthermore, it may be that GPCs are more willing to commission from a MM team that is set up not take profits out of the system.
Model c: pharmacy MM team forms a profit making company
You will see a fair amount of this. In fact, in our region, GPCs were encouraging a profit making company model. I guess it was kind of ‘why not join us in this new adventure’. Whereas actually it was more like, ‘we’ve all set up GP provider companies which make a profit, so what are you waiting for?’
What’s interesting about this model is that it takes away the responsibility from the GPCs that ‘they need to keep the team in existence’ or similar. Very often, I have encountered within England a GPC view that goes along the line of ‘we like what the team do, we think they should stay in some form, but we certainly won’t be coughing up £1million to keep them there’. That translates to: set yourselves up as a company, show us what’s on offer, and if it’s good, we may commission it. If it’s not then tough! That’s what being a company is all about.
Model d: GPCs opt for corporate management teams
This may not be good news. It’s the focus of a lot of critics of the White Paper. Remember when I said many of my colleagues had left the NHS? Well in keeping contact I have they are being sourced into companies such as Ernst & Young, Virgin Healthcare, AXA Medical, Boots, Lloyds and KPMG to name a few. Given many of these, if not all, have little or no medicines management commercial history, I decided to call them up and ask them what on earth they were doing there? This is the reply I keep getting: “They are building an army.” An army of high grade ex-NHS medicines management and hospital chief pharmacists. Why? To descend onto GP consortia and bring the world of the US-styled Managed Care Formularies to their doorstep. Most are starting on salaries of £85-£125k before bonus.
The offerings to GPCs will be tempting but with serious kickbacks. I can assure you if KPMG are running your territory GPC formulary, not only will they earn a fortune in return for prescribing costs that make the NHS QIPP program look like an F1 annual budget, but pharma will be very low down in the pecking order of accessing and influencing formularies. In fact, by the time you get there the prescribing guidance will have been truly done and dusted.
Omar Ali is the Formulary Development Pharmacist for Surrey & Sussex Healthcare NHS Trust.