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.

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.

Joint working has been recognised as a driver of therapeutic innovation at the second annual Quality in Care (QiC) Diabetes awards.

Partnerships between Eli Lilly UK and NHS and voluntary sector organisations were commended in an event that stressed the contribution of cross-sector work to the QIPP agenda.

Held at Sanofi’s UK headquarters in Guildford, the QiC Diabetes awards highlighted innovation and good practice in UK diabetes care.

A partnership between Lilly and diabetes charity JDRF to develop an educational programme on type 1 diabetes for schools was highly commended in the Best Cross-Organisational Partnership category.

Lilly was also commended for its partnership with Royal Surrey County Hospital NHS Trust to develop the ‘Piecing Together Diabetes’ clinician training tool, a jigsaw that helps staff to improve inpatient diabetes care.

“The awards have provided a unique platform to showcase good practice and innovation from across the country,” said Anna Morton, Director of NHS Diabetes. “We are all working under increased pressure and uncertainty and the examples highlighted have shown how despite adversity, high-quality diabetes care can still be achieved.”

Caroline Horwood, diabetes division director at Sanofi, commented: “We witnessed some inspirational work last year, and it is heartening to see that 2012 brings some new award categories and a 50 per cent increase in the number of entries.”

Quality in Care is a series of programmes aimed at recognising good ideas for improving care quality and productivity, in line with the QIPP agenda, and sharing them across the NHS.

The NHS operating framework provides the blueprint for the NHS in England. Pf examines its objectives around quality and reform.

The Operating Framework for the NHS in England 2012/13 is an important document for UK medical sales professionals. It outlines the national priorities, system levers and mechanisms that the NHS in England must focus on to improve patient care. The strategic framework details expectations for the NHS’ ongoing efficiency challenge and the transition to the new commissioning and management system. It sets out the planning, performance and financial requirements for NHS organisations and the basis on which they will be held to account. With QIPP imperatives at the heart of the strategy, proactive pharmaceutical companies that can demonstrate an ability to help NHS customers deliver efficiencies and improve qualities in areas of national priority will be best placed to succeed.

The Framework identifies four key themes for NHS organisations in 2012/13:

1. Putting patients at the centre of decision making in preparing for an outcomes approach to service delivery
2. Completing the final year of transition to the new system
3. Accelerating the delivery of the QIPP challenge
4. Maintaining a strong grip on services and financial performance.

Quality - a focus on outcomes

The Operating Framework says that the NHS’ model of delivery must be overhauled in 2012/13 to become a system driven by quality and outcomes. It identifies the Outcomes Framework as the catalyst for this – with its focus on clinical outcomes and the reduction of health inequalities driving changes in culture, behaviour and service delivery. The Outcomes Framework sets out the improvements against which the NHS
Commissioning Board will be held to account from 2013/14.

These measurements are set out within five domains:

Domain 1: preventing people from dying prematurely.

Domain 2: enhancing quality of life for people with long-term conditions.

Domain 3: helping people recover from episodes of ill health or following injury.

Domain 4: ensuring people have a positive experience of care.

Domain 5: treating and caring for people in a safe environment and protecting them from avoidable harm.

The Operating Framework details a range of indicators for each domain, all of which are explored in the NHS Outcomes Framework. These will be supported by NICE quality standards, which provide definitions of what high-quality care should look like for a particular pathway of care. The document also advises NHS organisations to meet the service specific outcomes strategies that have already been published in areas such as mental health, cancer, COPD, asthma and long-term conditions.

Each domain in the NHS Outcomes Framework has a strong relevance to pharma, whether through the development of medicines to treat disease in priority areas, or via collaborative service design to move care closer to patients’ homes and reduce hospital admissions. Organisations that are able to show how their innovations can improve a care pathway or be used as part of a redesigned service will enjoy
more positive NHS engagement.

The Operating Framework identifies dementia and care of older people as a key priority, and sets clear goals to integrate health and social care. It also highlights examples of initiatives where NHS organisations have successfully improved services in line with each of the four key elements of QIPP; quality, innovation, productivity and prevention.

Reform - the transition blueprint

The Operating Framework outlines the key milestones for the reorganisation of the NHS. Whilst the headlines are widely known, it is interesting to track current progress against a timetable that was set out many months before the Health & Social Care Act was passed. The Framework notes that by
the end of 2012/13:

“The NHS will have transformed the commissioning landscape into one focused on local clinical decision
making, with the development and authorisation of CCGs, assisted by commissioning support vehicles and overseen by the NHS Commissioning Board. Local authorities will take the lead role in public health, alongside the new Public Health England. Central to the new system will be the establishment of Health & Wellbeing Boards (HWB), who will provide local systems leadership across health, social care and public health. Alongside this, developments will continue to the provider landscape, through the extension of Any Qualified Provider (AQP), progress with the NHS Foundation Trust (FT) pipeline and the establishment of the new NHS Trust Development Authority.”

Key 2012/13 objectives in the transition are as follows:

• PCTs and SHAs will remain statutory organisations until April 2013. They will be held to account on delivering performance and support the development of new organisations for clinical leadership. Clinical Senates and networks will be established
• PCTs will support CCG authorisation and the transition of power before March 2013
• HWBs will be established in shadow format, becoming statutorily operational from April 2013. They will act as the local system leader through JSNA and HWB Strategies
• CCGs must be coterminous with a single HWB ‘as far as possible’
• CCGs must: play an active role in planning and budgeting, develop relationships with local partners
  including social care, deliver their share of the QIPP agenda and identify how to secure commissioning support services in line with their running cost allowance
• Public Health England will become a statutory executive agency from April 2013
• NHS Trusts are expected to achieve FT status by April 2014
• PCT clusters should start to offer patients choice of AQP in at least three services that are local priorities. There should be a presumption of choice for most services from 2013/14.

Innovative service redesign is enabling the NHS to meet the QIPP agenda of maintaining quality while cutting costs, Sir David Nicholson has said.

The NHS Chief Executive’s annual report highlights the contribution of locally-based initiatives to “a remarkable year for the NHS”.

Drawing attention to the Chancellor’s Autumn Statement, Nicholson said the issue of cost savings would dominate the NHS “for the foreseeable future”.

The report provides a summary of NHS achievements on five fronts: quality, innovation, productivity, prevention and transition.

Throughout, it uses examples of locally-based service redesign to illustrate clinical and economic improvement, including community-based asthma services in South-East Essex, COPD care in Surrey and stroke services in London.

Quality achievements highlighted include: the achievement of key cancer 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.

Progress towards delivering the innovation agenda outlined by the Government in December 2011 is celebrated, with Nicholson commenting: “Innovation has... to become the core activity of the NHS; the way we do our business.”

QIPP savings of £5.8 billion are noted, including £1.9 billion in the last quarter alone. Nicholson praises the “modest reduction in activity levels”, but does not refer to the issues of NHS rationing or cuts in hospital nurse staffing.

Increased risk assessment for VTE, with prophylactic drug treatment given where needed, is highlighted as an example of progress in preventative care.

The section on NHS transition covers the development of the NHS Commissioning Board, the new CCGs and “a wider range of providers from across the NHS, private and voluntary sectors”. Nicholson emphasises the role of service redesign in making the transition a reality.

There’s no better feeling than seeing the clock strike five on a Friday afternoon. The weekend brings two whole days where early morning alarm clocks and standing in line at the local Tesco at 1pm to buy a soggy sandwich are a distant memory.

Work-life balance has always been a difficult factor to measure – both for employers and their staff. Sure, companies want to get the most out of their staff – after all, a happy worker is a productive one. But should companies be doing more to give their workforce the Friday feeling throughout the rest of the week?

Recent figures from the Office of National Statistics show that workers in the UK trail only Greeks and Austrians for working the most hours in a week. The average full-time employee now works 42.7 hours. The Danes on the other hand manage to get away with doing only 39.1.

Unsurprisingly, the same report showed those happy Danes had a higher level of productivity per hour compared to the UK. In fact, 11 countries had a higher level of productivity per hour compared to over-worked UK employees. A happy, refreshed worker really is a productive one.

But is work-life balance judged solely on the amount of hours you work a week? Would you be happier with a smaller salary working part-time? I guess the answer in many instances would be no.

In an era when more people are having to take on additional responsibilities and enjoying less time with their families, employers have their own responsibilities to ensure staff can balance work, rest and play.

Flexible working hours – especially for representatives covering large territories – are appreciated, as are other ‘perks’ of the job. These may seen by some bosses as unnecessary and a hindrance, but it’s sometimes the little measures which are appreciated the most by those working at ground level.

In last year’s Pf Survey, respondents voted work-life balance as the fourth most important motivating factor. But, at the same time, it was also one of the least satisfying aspects of their job. Clearly, more still needs to be done to address the issue of balancing time spent at work and away from it.

Are you happy with your work-life balance? Does your company do enough to ensure you get chance to enjoy free time away from the office? Have your say today in the Pf Company Perception, Motivation and Satisfaction Survey here.

With financial experts warning of another global recession it’s a worrying time for both healthcare professionals and those currently without a job.

The Government in its ultimate wisdom last week revealed plans to eliminate certain discrimination laws in an attempt to make it easier for employers to do away with unproductive workers and replace those with a willingness to work.

But while the principle may sound simplistic, one boss’ judge of a productive medical representative doing their upmost to sell a dated product may be different to the person struggling to succeed in a crowded and competitive marketplace.

Instead of casting aside one unproductive worker for another, the Chartered Institute of Personnel and Development (CIPD) has called for the Government to scrap its intention to remove certain discrimination laws and instead focus on those with healthcare jobs, for example, to increase their skill set to improve productivity.

The CIPD’s calls aren’t exactly rocket science – yet they do make sense. Questions have to be raised why so many employees are unhappy with the level of productivity of their workforce. The reason may be closer to home.

More than a third of the workforce in the UK has managerial responsibilities. But how many of those dedicate time to improving the skill sets of their staff? Whilst training days or programmes may not provide immediate results the long term skills gain can yield rewards for years to come.

The key to unlocking productivity levels may not be with those set for the axe, but those wielding it in the first place.

London & Essex Medicines Management
Cardiology Discussion Forum Hosted by iRx Solutions, July 2011

Pharmacists have the appetite for medicines commissioning

The NHS landscape is changing, the shape of medicines commissioning especially. At a time when the NHS – like other parts of the public sector – is in financial dire straits, the Government is driving a radical overhaul of the structure of health and social care services, in England at least. But incoming CGCs will be crying out of support around medicines management and commissioning. It’s time for pharmacy to step forward.

According to Stuart Saw, Director of Finance at NHS East London and the City Alliance, the recent listening exercise and “pause” of the Health and Social Care Bill’s journey through Parliament has not resulted in substantial changes to the direction of travel. “Irrespective of what people thought the pause might bring, the momentum was already there before the pause was called and it’s impossible to turn around,” he told guests at a cardiology discussion forum, held by iRx Solutions in London last month.

It is this momentum that will, in all probability, see the formation of some 500 Clinical Commissioning Groups, formerly known as GP Consortia, replacing around 150 Primary Care Trusts, which are to be abolished.

Omar Ali (pictured above right, with Jayesh Shah and Victoria Overland), a formulary pharmacist in the NHS, and one of three directors at iRx Solutions, suggests that these commissioning groups will be crying out for support around medicines management and commissioning, and believes that pharmacists have the necessary talent to fill the gap. “We have experienced firsthand how much sway pharmacists have as decision-makers within the NHS. This cultural change has happened over a number of years but has resulted in our profession being in a prime position to help deliver a new outcomes-focused healthcare system, which needs our expertise – and needs it urgently,” he said.

Mr Ali and fellow iRx Solutions directors, Victoria Overland and Jayesh Shah, also NHS pharmacists, came together in 2010 to consider how they could facilitate sharing of ideas and good practice among such influential pharmacists. Their vision: a suite of medicines-related solutions, including specialist education and medicines commissioning support, delivered by expert pharmacists to colleagues in ‘payer’ roles. Their recent cardiology discussion forum was a refreshing mix of good food, sponsored and non-sponsored presentations, and debate – attended by prescribing advisers, heads of medicines management and other pharmacy leaders.

Victoria Overland, who comes from a background as a commissioning pharmacist in primary care, says that pharmacists are now among the key decision-makers and are well placed to influence both prescribing and commissioning in the new NHS. “Therapy choices made by GPs,” she explains, “are currently supported by PCTs, which have a wealth of commissioning experience – balancing effectiveness and outcomes with the costs to the health economy. When the PCTs disband, this requirement for high-quality medicines commissioning support will still exist. What will be different about it is that Clinical Commissioning Groups will be making decisions that they feel best suit the needs of highly localised populations. We know that pharmacists have a great deal of experience in reviewing the efficacy and safety of medicines, and, crucially, their impact on healthcare budgets.”

So what did participants hear about at the discussion forum? Cardiology content was served up alongside presentations from Stuart Saw, who described the challenges being faced with the NHS reconfiguration, and Omar Ali, who gave an express tour of how value-based pricing of medicines might work in the future.

Helen Williams, Consultant Pharmacist for cardiovascular disease in south London, outlined how appropriate changes in drug therapy could support the Government’s QIPP – quality, innovation, productivity and prevention – agenda. Conversely, she questioned the wisdom of switching patients from certain branded angiotensin-receptor blockers (ARBs) to generic losartan. Ms Williams argued that some of the branded ARBs are due to come off patent in the near future and that the healthcare costs associated with switching therapies – not to mention the potential disruption for patients – might not be justified.

“We had nine years between simvastatin patent expiry and atorvastatin patent expiry and, as a result, we’ve saved millions,” she told attendees. She pointed out that the losartan patent expired in March 2010, adding: “We’ve got valsartan [expiring] this year and we’ve got candesartan and irbesartan next year. So I think we’ve missed the boat. If we wanted to make savings . . . from generic losartan, specifically, we needed to plan for it in 2008–09.”

Stable angina was also on the menu, with the profile of the condition set to be lifted following the publication of a new clinical guideline by the National Institute for Health and Clinical Excellence. Making clear that the NICE guideline was only in its draft form (when the discussion forum took place), Sotiris Antoniou, Consultant Pharmacist CV Medicine NE London CV & Stroke Network Barts & London NHS Trust, described the place in therapy of the range of medicines available for treating stable angina patients in the UK. He emphasised the need for clinicians, when interpreting NICE guidance, to “think about the whole patient” and his or her quality of life.

This is something that Jayesh Shah understands all too well from working as a medicines management pharmacist, supporting GP consortia. “With so many changes since the White Paper was published last year, there is a lot of confusion among both clinicians and managers,” he says. “But something we are certain about is that healthcare professionals care a great deal about their patients and want the best outcomes for them. So that’s our passion and driver, and meeting the ambitious goals of the QIPP agenda is also an imperative.”

According to Mr Shah, a healthy dialogue between pharmaceutical companies and pharmacists – “we need to think creatively about this relationship” – will help the industry to align its priorities with those of the evolving NHS. Omar Ali adds: “We are committed to working with the pharmaceutical industry to ensure all aspects of our educational events meet regulatory requirements. Moreover, iRx Solutions is committed to ensuring the quality of the content and speakers is exceptional. But we know that this kind of meeting is about more than the educational programme: both pharma and medicines management attendees see the value in time put aside for networking.”

Progress of the NHS reforms may have slowed, but it appears that momentum is building in at least one profession to tackle whatever the Government manages to push through Parliament. If the opinions of the team at iRx Solutions are anything to go by, pharmacists certainly have a bright future as decision-makers around medicines.

The directors are speaking on behalf of iRx Solutions not the NHS organisations by which they are currently employed. For more information on iRx Solutions, visit www.irxsolutions.co.uk.