The focus of NHS investment needs to shift from large acute hospitals to community and home-based services, according to the NHS Confederation.

A new report, Transforming Local Care, argued that “significant” investment in making the community the “default setting” of healthcare is needed to meet the combined pressures of increasing demand and shrinking budgets.

Hospital inpatient services can be reserved for complex surgery and treatment of life-threatening conditions, the report said – but major and visible improvements in community-based care need to take place at the same time.

The NHS Confederation, which represents commissioner and provider organisations, called for long-term condition management to be shifted decisively out of the hospital framework.

It highlighted the proven value of strategies such as home monitoring, mobile diagnostics and medication adjustment in helping to keep people out of hospital.

While these strategies were recommended by Lord Darzi’s NHS review in 2008, the “unprecedented” economic pressures have made them urgent priorities for national adoption, the report argued.

Calling on the NHS Commissioning Board to “facilitate the necessary shift in the financing of care”, the Confederation outlined the need for payment incentives to promote prevention, early intervention and early supported discharge.

Crucially, it added, efficiency savings must be reinvested in community-based services, instead of being claimed by the Treasury (as currently happens).

“It is time we started thinking differently and making sure investment supports innovative service delivery that supports patients’ independence and recovery,” said Jo Webber (pictured), the NHS Confederation’s interim Director of Policy.

“For too long, the default setting when we think about healthcare or support is to think of a hospital. But in reality, acute hospitals are rarely the best place for someone who needs ongoing treatment.”

The global market in statins, once the pharmaceutical industry’s lead blockbuster products, is predicted to decline by 40% in the next five years.

The forecast by GBI Research of a negative CAGR of 7.2% up to 2013 for the cholesterol-lowering drugs is based on prospects of generic erosion, weak pipelines and failing prescriber confidence.

The decline in the statins market shows that the shift of healthcare towards prevention and management of long-term conditions is not without pitfalls for the pharma industry.

Statins, which lower cholesterol levels by targeting an enzyme in the liver, have been hailed as ‘wonder drugs’ that could radically reduce the global incidence of cardiovascular events.

Routinely prescribed for ‘high-risk’ patients such as people with high blood pressure or diabetes, statins have also been linked to reduced risk of bowel cancer and reduced death rate from influenza.

However, their global market declined from $23.7 billion in 2004 to $20.5 billion in 2011 (a negative CAGR of 2.5%), due largely to patent expiry.

The report predicts a much steeper decline in the statins market over the next five years, for four reasons:

• Patent expiry – the generic share of the statins market is predicted to grow from 11% in 2011 to 34% in 2018.

• Austerity health budgets – spending on prevention is likely to be cut back.

• Weak product pipelines – the ‘me-too’ nature of most statins betrays a lack of potential for innovation.

• Increased use of alternative drugs.

Medical writer Ben Goldacre has argued that the marketing of statins in terms of relative risk reduction glossed over the low absolute risk reduction they offer, and left the products open to a backlash over side-effects.

Statins are associated with both symptomatic side-effects (including digestive disorders) and potential ones (including increased risk of type 2 diabetes).

As the overall statins market declines, the report says, individual products will struggle to gain or keep a place within it: “The global statins market has reached the competitive stage of its lifecycle, with many branded and generic drugs competing with each other on price.”

New draft NICE guidance recommends giving tamoxifen or Evista (raloxifene) to women with a family history of breast cancer as a preventative drug.

The provisional guidance update makes new suggestions for genetic testing, screening and preventative treatment in women at high risk of breast cancer.

If confirmed by NICE, the recommendations would mean the first use of a drug by the NHS to prevent breast cancer.

Breast cancer is diagnosed in 50,000 women in the UK each year. Women with a sister and a mother or aunt who have developed breast cancer before the age of 50 are considered at high risk of developing the disease for genetic reasons.

Breast cancer is also likely to occur earlier, and to be harder to treat, in this patient class, who are fewer than 1% of women aged under 30.

Genetic testing can identify either of two mutant genes that are linked to increased risk of breast cancer, as well as ovarian cancer.

NICE emphasises the need to reduce the incidence of breast cancer in high-risk women. It estimates that for every 1000 women treated with tamoxifen or Evista for a five-year period, there would be 20 fewer cases of breast cancer.

However, the drugs have side-effects including increased risk of blood clots, so their preventative use would need to be carefully considered.

Tamoxifen was developed by AstraZeneca but has long been off patent. Lilly’s Evista came off patent more recently. Neither drug has UK marketing authorisation for prevention of breast cancer.

Chris Askew, Chief Executive of the charity Breakthrough Breast Cancer, said the draft guidance was “a historic step for the prevention of breast cancer”.

Novo Nordisk has partnered with sporting organisations to launch a global sports team with more than 100 cyclists and athletes, all of whom have diabetes.

Team Novo Nordisk will compete in more than 500 sporting events worldwide in 2013, promoting effective diabetes control as a road to health and success.

The global team comprises cyclists, runners and triathletes, including the world’s first all-diabetic professional men’s cycling team.

The cyclists will compete in the USA Pro Cycling Challenge, the Tour of Britain and the Paris-Tours, with the goal of qualifying for the Tour de France.

“We stand for what life with diabetes can be like,” said Phil Southerland, founder of Team Novo Nordisk. “Exercise is that billion-dollar drug that nobody ever gets prescribed, and in my experience is the best of them all.”

Jakob Riis, Novo Nordisk’s Senior Vice President, Global Marketing and Global Medical Affairs, commented: “As part of our long-standing Changing Diabetes programme, this partnership provides a tremendous opportunity to raise awareness, and educate, empower and inspire people with diabetes.”

Changing Diabetes is Novo Nordisk’s global advocacy and partner platform, working to promote the prevention and early diagnosis of diabetes, as well as more effective treatment and care.

The Danish company has specialised in the treatment of diabetes for nearly 90 years, but only in the last decade has it seen the disease area become the developed world’s leading health issue.

Urgent action by public health authorities is needed to address the rising prevalence of liver disease in England, the Chief Medical Officer has said.

Professor Dame Sally Davies noted that in the last decade, the incidence of liver disease has grown here by 20% while falling by a similar amount in Europe.

The CMO’s first annual report also highlighted the need for better access to healthcare and better public health surveillance as priorities.

The report is intended to guide and inform the public health strategies of local government and the new Health and Wellbeing Boards.

Drawing on international data, Davies commented that liver disease “is the only major cause of mortality and morbidity which is on the increase in England whilst decreasing among our European neighbours.”

The main causes are heavy drinking, obesity and undiagnosed hepatitis infection, but late diagnosis contributes to poor outcomes – so the report calls for a combined preventative and early intervention approach.

Variations in access to healthcare were also highlighted, with diabetes monitoring a particular area of concern – only 50% of people diagnosed with diabetes receive all nine NICE-recommended annual tests.

Public health surveillance was a third priority emphasised by Davies, who called for better information on significant but non-fatal diseases such as musculoskeletal and skin disorders, cognitive and sensory impairment, and incontinence.

In addition, she warned, cutting costs on public health surveillance could leave populations exposed: “The history of public health suggests that it is not enough to prepare for the health problems we already know about.”

Strikingly, Davies praised the contributions of the cancer registries and the Health Protection Agency – both due to be abolished in 2013.

Health spending is falling across Europe, leading to neglect of public health strategies, the Organisation for Economic Co-operation and Development (OECD) has warned.

The OECD report observed that austerity measures are leading governments to focus spending on acute care, while preventative strategies such as immunisation and smoking cessation are neglected.

Health spending per person in the EU has fallen from an average annual growth rate of 4.6% between 2000 and 2009 to −0.6% in 2010.

The UK is typical, with a drop in health spending of 0.5% in 2010 after a decade of annual growth at 4.9%.

Other countries further along the austerity road show a steeper decline – for example, health spending in Ireland fell by 7.9% after a decade of 6.5% growth.

As Shadow Chancellor, George Osborne stated in 2006 that Ireland’s economy was a model the UK should follow.

The OECD report notes that smoking and obesity are the major risk factors for cardiovascular disease, which caused 36% of all deaths in Europe in 2010.

Obesity rates have doubled across Europe since 1990, now at 17% of the population – and 25% in the UK.

“Governments under pressure to protect funding for acute care are cutting other expenditures such as public health and prevention programmes,” noted the OECD.

“In 2010, on average across EU countries, only 3% of health budgets were allocated to prevention and public health programmes in areas such as immunisation, smoking, alcohol, nutrition, and physical activity.”

The effects of this neglect of preventative healthcare will be seen in the coming years, the report warned.

The NHS Quality, Innovation, Productivity and Prevention (QIPP) programme has been broken down into its components following the resignation of its leader, Jim Easton.

The role of the former National Director for Improvement and Efficiency at the NHS Commissioning Board will be divided between four other national directors and SHA leader Sir Ian Carruthers.

Easton (pictured), who has left the NHS to head private health provider Care UK, warned in May that QIPP had become a ‘label’ for NHS spending cuts without service redesign.

Then changes mean that the QIPP programme will not have a specific team or individual leader to drive it forward.

According to the Health Service Journal, the decision not to replace Easton was made to reduce the Board’s running costs and because his role had been uniquely created for his skills.

Easton’s former responsibilities will be divided as follows. Sir Bruce Keogh’s medical directorate will be responsible for a new NHS improvement body, led by the five clinical domain directors. Bill McCarthy’s policy directorate will be responsible for strategy, including medium-term QIPP strategy. Jo-Anne Wass’s HR directorate will be responsible for the new Leadership Academy. Ian Dalton’s operations directorate will be responsible for productivity improvement.

In addition, NHS South West Chief Executive Sir Ian Carruthers will take over the leadership of NHS innovation.

The payment by results (PbR) system for healthcare reimbursement is unfit for meeting the changing needs of society, according to the King’s Fund.

The think tank identified the current tariff as a barrier to the shift of healthcare from hospitals to the community.

A range of payment systems would be needed, the report argued, to encourage local innovation and to balance the priorities of quality, cost and supply.

The report explored the payment systems used in the NHS and other health economies, and examines whether PbR is able to support such long-term objectives as disease prevention and the care of long-term conditions.

Payment by results incentivises hospitals to continue treatment, thereby blocking a shift to preventative and community-based care, the report said.

It concluded that different services require different payment systems: PbR is most appropriate to elective care, but less suited to other services.

In addition, the King’s Fund said, payment systems need to be flexible to assist adaptation at a local level and trade-offs between priorities.

The NHS needs a new reimbursement framework that allows different payment systems for different types of service, the report argued.

Monitor, the foundation trust regulator, commented that it could “recognise many of the areas for improvement identified in the report” and would give it “careful consideration” when developing its pricing strategy.

Health Minister Lord Howe said: “We are working to make sure a payment system supports care being delivered closer to patients’ homes.”

He added: “We are working to expand our best practice tariff programme which supports patient-focused care, encourages innovation and makes better use of resources.”

Is QIPP really about ‘doing more with less’?

The NHS Quality, Innovation, Productivity and Prevention (QIPP) Challenge was launched in March 2010 as a strategy to facilitate major cost savings within the NHS, in response to the impact of the global recession. The principle of QIPP was that given the need for austerity budgeting, serious planning and rethinking were needed to ensure ‘smart’ cost-cutting that did not harm patient outcomes. The QIPP agenda was about identifying solutions that held together the four key principles, reducing overall costs by making interventions more timely, efficient and effective.

The new Government’s NHS reforms promised to facilitate QIPP by empowering local providers and commissioners to develop the best solutions for their communities. However, the economic pressures on CCGs and Foundation Trusts within the new system, combined with the ‘Nicholson challenge’ of cutting £5 billion out of the NHS budget in each of four successive years, have meant that the dominant theme of QIPP at a local level is cost reduction.

The first full year of QIPP (2011–12) delivered savings of £5.8 billion against a target of $5 billion. However, reports of NHS rationing and ‘postcode prescribing’ have proliferated. QIPP was devised as a strategy to combine two goals: the shift towards community-based healthcare and the urgent drive towards NHS cost-cutting. Is that still the agenda, or have the pressures of NHS reform reduced its four principles to one: reducing expenditure? Is QIPP really about “doing more with less”, as Andrew Lansley claimed, or is it just about doing with less?

A new healthcare paradigm
The DH booklet introducing the QIPP challenge in March 2010 set the context: “The NHS needs to identify £15–20 billion of efficiency savings by the end of 2013/14 that can be reinvested in the service to continue to deliver year on year quality improvements.” The booklet placed emphasis on improving quality while reducing overall costs through strategies such as early intervention, improved infection control and home-based care. Its authors included Jim Easton, then National Director for Improvement and Efficiency. The DH described a series of QIPP ‘workstreams’ it was setting up to help clinical teams and NHS organisations “improve quality and productivity across care pathways”. The first of these related to care of long-term conditions, urgent care and end-of-life care. Further workstreams would examine safety challenges, such as pressure ulcers (bedsores), and ‘right care’ issues such as referral management and identifying “low-value treatments” (later to become controversial issues).

The authors called for “a collective response at local, regional and national level” to address the QIPP priorities. These included early diagnosis, primary and secondary prevention and patient self-management. The need for “better partnerships between primary, community and secondary care to support people with long-term conditions” was emphasised. QIPP extended from the “daily clinical practice” of individual HCPs to “the wider care pathway”, the booklet said. Each SHA had its own QIPP lead and innovation lead, and was establishing an online regional ‘quality observatory’ and Innovation Fund to help clinical teams improve quality and productivity.

These ideas were illustrated by case studies where local NHS organisations had developed better and more affordable healthcare solutions. These included the use of an electronic system to ‘re-engineer’ blood transfusion, reducing waste and improving safety; and systematic guidance on antibiotic prescribing to reduce rates of C. difficile infection. These solutions all involved using teamwork and sharing information to make the best use of available resources.

The booklet ended on a warning note: “If we do not respond to this challenge there is a real risk that the need to cut costs will overtake our best intentions to improve care for our patients.” More than two years later, the crucial question is: has QIPP averted that outcome or brought it closer?

Innovation is ‘core activity’
In June 2012, Nicholson’s annual report claimed 2011/12 had been “a remarkable year” for the NHS. He highlighted the contribution of local initiatives to maintaining service quality while cutting costs. Austerity would dominate the NHS “for the foreseeable future”, he said. However, the innovation agenda promoted by the previous Government’s Office for Life Science and revived by the current Government in December 2011 would engage dynamically with that challenge: “Innovation has to... become the core activity of the NHS.”

His report went through the elements of QIPP, noting achievements in each area. Quality achievements highlighted included: in cancer care, the achievement of key treatment standards across all eight performance measures, as well as improved early detection figures; and in stroke care, better access to specialist stroke units and faster treatment of people with transient ischaemic attacks. Community-based asthma services in South East Essex were used as an example of a successful local initiative.

The brief section on innovation focused largely on the use of technologies in the community, including telehealth and home dialysis. The preventative care section emphasised the growing role of health visitors, and drew attention to the success of a national screening campaign for risk of venous thromboembolism (VTE) with prophylactic drug treatment given where needed.

In the productivity section, Nicholson noted QIPP savings of £5.8bn and praised the “modest reduction in activity levels” across the NHS – placing these in the context of the QIPP Long-term Condition Workstream, which aims to reduce unscheduled hospital admissions by 20%, reduce hospital stay length by 25%, and maximise the role of “supported care planning” in helping people to manage their own health. However, no reference was made to the rationing of procedures or the cuts in hospital nurse staffing.

Milestones or millstones?
A recent Health Service Journal report on the DH’s QIPP tracker indicates that the PCTs (soon to be abolished) plan savings worth £13bn nationwide between now and 2015, with £4.5bn of this to be achieved through the 53 local QIPP plans. The planned savings are front-loaded: £3.8bn this year and £3.6bn, £2.9bn and £2.6bn in the next three years. However, only £2bn of the planned QIPP savings are currently being achieved on schedule, and only six local QIPP plans are on track with all of their workstreams.

According to the tracker, productivity gains are the main objective of most local initiatives. Common features include the redesign of care pathways for long-term conditions, including diabetes and COPD, and the development of integrated care teams for dementia patients. However, many local plans have the single goal of reducing the cost of services – for example, South of Tyne and Wear PCT notes as an objective: “reduce price paid for Gateshead Health Foundation Trust older people’s mental health service”.

John Appleby, chief economist of the King’s Fund, commented that this emphasis on savings denied the original point of QIPP: “to improve value to patients”. He also said there was no evidence of the money saved being reinvested in future services, which was a key principle of the original QIPP agenda. The Audit Commission has since reported that the NHS has £4bn in “uncommitted finances”: cash reserves created by aggressive cost-cutting. Mike Farrar, Chief Executive of the NHS Confederation, has argued that this money needs to be invested in community and primary care.

Jim Easton, the NHS Commissioning Board’s Director of Improvement and Transformation, warned in July that too many NHS organisations were relying on spending cuts without any element of service redesign. The “deeper change” of shifting healthcare to the community was not being undertaken, he said, and
QIPP was becoming a “label” for “cost improvement plans”. As a result, the QIPP savings of the past year would be very difficult to repeat. Instead of building a new healthcare model, the NHS was just cutting
parts of the old one.

Easton has since announced that the Board will fund a new innovation body to deliver a “system-wide” response to the QIPP challenge. From April 2013, the new organisation will replace all existing NHS innovation and technology adoption bodies. He anticipates that it will “provide hands-on support for great models of care” developed within and beyond the healthcare sector. However, his resignation has cast a shadow over these plans.

According to the King’s Fund, 27 of 42 NHS finance directors it surveyed believe there is a high risk that the NHS will fail to meet the ‘Nicholson challenge’. A key question for industry, and for patients, is whether QIPP can help the NHS deliver on the more important challenge of transforming healthcare to meet the
changing needs of the population.

Mike Farrar, Chief Executive of the NHS Confederation, has said the growing crisis in hospital funding demands major investment in community-based healthcare.

His statement follows an Audit Commission report showing that the number of hospital trusts in deficit increased from 13 in 2010/11 to 31 in 2011/12.

While the report called for tight control of trust finances, Farrar argued that the underlying problem is the over-dependence of the NHS on acute care.

The Audit Commission’s annual report on NHS finances said that while PCT finance was mostly healthy, there had been a dramatic increase in the number of foundation trusts and NHS trusts in debt.

There was “no room for complacency” over hospital trust finances and the need for tight spending controls, the Commission said.

Andy McKeon, its Managing Director of Health, commented: “The Department of Health and other relevant national authorities need to focus their attention on the minority of organisations whose financial position is deteriorating and on their geographical distribution and service standards.”

Farrar, who has long argued for a shift in funding from acute to preventative and long-term care, said: “This is the time for the NHS Commissioning Board to help providers, not with bailouts, but by releasing money to new CCGs so they can work with providers to help put them on a sustainable footing by changing the type and range of services they provide.

“Now is the time for big investment in community and primary care. It is worrying that the number of trusts in deficit has more than doubled in the past year. This situation is likely get worse unless we take radical action.”