Paul Midgley and Steve How, of Wilmington Healthcare, look back at some of the key developments in the NHS in the past year.
To plug an anticipated £22bn hole in its budget by 2020, the NHS must improve efficiency. Transforming services is key to making the NHS sustainable and, in 2017, new integrated models of care and budgetary management, trialled by vanguards, have been upscaled.
In line with the Five Year Forward View (5YFV), which was updated in March, vanguards have been helping to incorporate their new models of care into Sustainability and Transformation Partnerships (STPs), and we have seen change taking place at varying speeds, both clinically and geographically.
Eight areas in England were also confirmed in June to lead the way in a new budgetary system, known as an Accountable Care System (ACS), that will be officially launched next year. This has occurred against a backdrop of growing financial pressures on the NHS that have included prescription medicine cuts and a price cap for new drugs.
Other notable developments in the NHS this year have included an increased focus on data integration and capture to support transformation and the appropriate use of new treatments and technologies. In line with this, we have seen the publication of the proposed Life Sciences Industrial Strategy, which aims to make the NHS a unique international, data centre, pioneering the use of new medical technologies.
The expansion of vanguard programmes
As vanguards entered their final full year of operation in 2017, a key objective was to support others to learn from their experiences, and to expand and spread their new care models through the Sustainability and Transformation Partnerships (STPs) that were launched in April.
For example, in some STP areas, Multispecialty Community-Based Provider (MCP) vanguards and Primary and Acute Care Systems (PACS) vanguards have been developing new, integrated models of care that leverage innovation by encouraging providers to work collaboratively for longer. Both models will be central to the way that the new Accountable Care Systems (ACSs) are delivered.
The rise of the ACS model, which is due to go live in April 2018, is seen as the most effective way for STP footprints to deliver integrated care across provider settings. ACSs will operate on an outcomes-based contract to one integrated provider or will administer a single budget, known as a capitated budget. This method enables the physical, mental and social care needs of a defined population to be managed by a single entity or group of providers, which receive a regular lump sum from each of the other providers in their network.
The ACS model favours outcomes-based commissioning and long-term contract arrangements of five to 10 years, rather than one year, to encourage more investment in appropriate areas.
When he addressed the NHS Confederation in Liverpool, in June this year, Simon Stevens, Chief Executive of NHS England, announced that eight areas in England would become ACSs.
The first group of designated ACSs have agreed with national leaders to deliver fast track improvements set out in the Next Steps on the 5YFV, including taking the strain off A&E, investing in general practice, making it easier to get a GP appointment, and improving access to high quality cancer and mental health services. A huge amount of work has been done on ACSs in 2017 to prepare for next year’s launch.
Growing financial constraints
During 2017, NHS trusts and Clinical Commissioning Groups (CCGs) have come under increased pressure to budget meticulously and not exceed their financial control totals, which set targets for the maximum deficit or minimum surplus they are expected to achieve.
In the spring, NHS England and NHS Improvement claimed that while some trusts and CCGs had generated savings since the publication of the 5YFV in 2014; others were still overspending and effectively ‘living off bailouts from other parts of the country’.
In response to this, NHS Improvement and NHS England introduced the Capped Expenditure Process (CEP) to ensure that under-performing trusts and CCGs deliver on their control totals and do not exceed their budgets. It was imposed on 14 CCGs and trusts, which were told they must make ‘difficult choices’ to stay within the combined funding envelope for their area.
Medicines Management Changes
CCGs have also been coming under increased pressure to improve services and cut prescription spending costs this year as part of the 5YFV’s NHS Rightcare Programme. Rightcare has been tasked with helping CCGs to identify where they are wasting money on sub-optimal healthcare and define how their products and services could be changed to improve outcomes and save money.
According to Simon Stevens, NHS prescriptions have risen by 50 per cent in a decade and GPs are now handing out more than a billion of them each year at a cost of £9.3bn. In a bid to cut spending in this area by up to £400m annually, he announced in March that the NHS planned to stop prescribing low value medicines that could be easily bought over-the-counter, such as antihistamines and sun cream.
In 2017, it was also announced that CCGs would be monitored by four Regional Medicines Optimisation Committees (RMOCs) which were launched to avoid duplication when evaluating medicines, particularly those which are not evaluated by NICE. The RMOCs will co-ordinate medicines optimisation opportunities in a variety of settings including care homes. They will also look at multiple prescribing, use of generics and biosimilars, and reducing medicines wastage.
NICE cap on new medicines
As part of NHS England’s bid to drive down costs, a price cap was introduced in March on new medicines. It means that the NHS no longer must automatically fund drugs forecast to cost more than £20m in any of the first three years they are in use. Instead, the NHS can opt to enter commercial talks with the manufacturer to try to negotiate the cost down. If this fails, it can ration the roll-out of the drug. The Association of the British Pharmaceutical Industry (ABPI) took the NHS to court over the matter but lost.
There has also been uncertainty over the Pharmaceutical Price Regulation Scheme (PPRS) as it has sought to cap the amount of profit that a pharma company can make and reduce the risk for the NHS in bringing a new drug to market.
Rise of data integration and data capture
NHS organisations cannot make significant improvements to their services without a detailed knowledge and understanding of how they are currently performing, and where problems and inefficiencies exist.
Although industries ranging from retail to insurance have been successfully harnessing big data for years to improve products and services, the NHS has struggled to capitalise on complex data. This is largely because primary and secondary care data has been stored in silos.
Digital transformation is integral to STPs and each STP footprint has a digital transformation plan to tackle the issue. Some of these STP digital plans are built on integrating data from existing systems and some are being started from scratch.
To support transformation and appropriate use of new treatments and technologies, the NHS is now beginning to join up data that links activity to outcomes across primary and secondary care (digital roadmaps) and enables it to map the cost of cohorts of patients within a treatment pathway.
In August, Sir John Bell published his recommendations for the Life Sciences strand of the Government’s Industrial Strategy. If his vision is realised, the NHS could be used as a laboratory for international organisations to test theories and measure costs across a wide variety of care settings to support the introduction of new, innovative technologies and treatments. It could also allow accelerated access products, such as cancer immunotherapy drugs, to generate real world data quickly to support clinical trial findings.
Sustainability and transformation were the name of the game for the NHS in 2017 as new models of care, trialled by vanguards, were upscaled into the new place-based STPs that were launched in April, against a backdrop of growing financial constraints.
From combining budgets to joining up patient data, the new models of care are all about integration. By taking a collaborative approach, the NHS aims to not only make its services work in a more cost-efficient and patient centric way, but also become a global health information leader.
The NHS may have a long way to go in its bid to transform services to meet the needs of the ageing population and the associated burden of chronic diseases, but 2017 has clearly been a year of immense change as the NHS has continued to implement the objectives laid out in the 5YFV. It’s clear too that there is a valuable, if not essential, role that pharma and healthcare technology can play during this period of change.