Are the latest NHS changes just more arbitrary reorganisation or something more compelling?
Through the key changes
1. A focus on population health and outcomes, with a whole raft of meaningful outcomes, including heavy issues, such as life expectancy.
2. A long-term approach with financial incentives. The Multispecialty Community Provider contract runs for 10 years or longer, and the incentives are aligned to improvements in outcomes.
3. Incorporating integrated services, breaking the barriers between primary and secondary care, health and social care, and developing multi-disciplinary teams for specific patient groups. In many areas, this also includes voluntary sector and other community assets.
The NHS reorganisation of 2013 was described by Sir David Nicholson, then Chief Executive of the NHS, as being “so big you can see it from the moon”.
Andrew Lansley’s goal was to dismantle and reassemble much of the architecture of the NHS; a plan which seemed to get bigger by the month. One bright idea for change triggered a litany of plans to plug gaps and silence dissent, while the simplified system got more complex.
Many have their own views on whether those reforms were worth the upheaval, or if we should reserve judgement until some undefined future, when it all either works or fails. The current changes happening in the NHS, however, feel more significant than what happened in 2013.
We don’t have a new Act of Parliament or new types of organisation. We do have a whole new approach, which many at the sharp end of commissioning see as the most fundamental and exciting change in healthcare delivery since the conception of the NHS.
So, who’s developing these plans and what’s the big idea? Well, despite my enthusiasm, it’s a bit of a challenge to nail down. It, of course, involves the Five Year Forward View, Simon Stevens’ vision and the document that kick-started the new approach. The plan introduced ‘New Care Models’ and ‘Accountable Care Organisations’ (ACOs).
The oversight of the local plans involves the STPs – Sustainability and Transformation Partnerships (formerly plans) – which are not new organisations, but rather a collaboration between local health and social care leaders to drive forward ‘place-based’ plans for service reconfiguration.
Accountable Care Systems are an alternative to the big ACO procurements currently being undertaken in some areas. They bind organisations through an ‘alliance agreement’ and, importantly, emphasis is placed on organising community care in hubs which support 30-50,000 population. This latter approach is based on the ‘Primary Care Home’ model developed by the NHS Confederation at grass roots level.
These developing organisations and alliances carry a weight of expectation relating to the anticipated cultural change. A focus on outcomes, rather than transactions, will mean a greater emphasis on aspirations rather than specifications, uniting stakeholders in quality improvement activities. The contracts being developed also place providers under pressure to exert systems leadership and affect change outside their direct control, for example, influence over education,housing, transport and leisure.
Now we come to the inevitable and recurring question – what it means for pharma. Arguably, the biggest opportunity relates to being part of a system which incentivises performance in improving patient outcomes. This does prompt two further, somewhat familiar questions, which companies may be wrestling with.
Can both pharma and healthcare providers enter into meaningful yet pragmatic, outcome-based commercial relationships or will it be business as usual? And, if relationships rooted in outcomes can work, is there enough financial headroom to allow the incentives to reach a pharma partner?
The first question relates to each party’s willingness to take risks, work through potentially tricky compliance and procurement barriers, and perhaps most importantly, the ability of both to simply make it work on the ground.
I have rarely met anyone from pharma who is content for their role to be simply selling medicines. Most want to develop and work in partnerships with the NHS, but a number of challenges come with this.
Can you shift from a single product focus to a pathway, programme of care, or population, even if it means working with other companies? A second challenge comes from the need to influence things outside your control or remit, for example supporting a prevention agenda.
A key challenge for those in the NHS is learning to trust and understand the commercial sector and give both parties the freedom to make it work.
If we can get to this Nirvana – and in my opinion, this is the best chance we have ever had – then will the economics work, not just on paper, but in the real world with real patients?
I’ll be taking on these opportunities and challenges in the next two issues.
Dr Duncan Jenkins is a Director at MORPh, specialist training providers for CCG, clinical, practice and GP pharmacists.Go to morphconsultancy.co.uk