In last month’s PharmaTimes, we explained how recently updated guidance for NHS commissioners puts front-line clinicians at the heart of driving and assuring major service change, based on the best available evidence.
However, one barrier to this style of working advocated in NHS England’s Planning, assuring and delivering service change for patients, is that clinicians often struggle to engage with commissioners because they have very different priorities.
Another problem is that transformational change tends to be initiated at the top level within the NHS and clinical consultation is limited; consequently, many clinicians do not get a chance to comment on proposals until they have been implemented.
Change is instigated at the highest level in the NHS
There is a real drive for change within the NHS with ten areas preparing to become Integrated Care Systems (ICSs), for example. However, discussions and decisions about transformational change mostly take place within the highest echelons of local NHS organisations.
If you dive beneath the surface, it is business as usual for many NHS staff, with little pockets of change occurring in some places. When transformation teams do engage with staff from other parts of the service, it will generally be with small groups of clinical leaders; hence many ‘jobbing’ clinicians are left in the dark about change until it occurs.
To cite an example, NHS musculoskeletal (MSK) services have recently been transformed in an STP area. A key result is that GPs will now refer a patient with MSK problems to a triage nurse in the first instance, rather than a consultant. This is clearly a major change in the care pathway, yet the transformation teams did not seek the consensus view of all consultants before going ahead and the physiotherapy team was not consulted at all. This lack of communication often occurs because the scale and pace of change in the NHS limits engagement.
NHS England’s Planning, assuring and delivering service change for patients, which provides a good practice guide for commissioners on the NHS England assurance process for major service changes and reconfiguration, makes it clear that this is not the way in which change should be implemented, since it states that clinical engagement and approval, and strong clinical evidence are key. The guide, which can also be applied to lower levels of change, such as the introduction of new drugs to improve care pathways, provides a powerful opportunity for pharma to activate clinicians to take a lead in service change and engage with other key stakeholders.
It can also help pharma ensure that it fully understands the tests and assurance checks that should be applied to new drugs and services. For example, one question in the best practice assurance checks asks: ‘Is it clear how the proposal fits into the STP financial plan?’ Another asks: ‘What contribution do the proposals make to each of the three gaps described in the Five Year Forward View (health and wellbeing gap; care and quality gap; funding and efficiency gap)?’
Getting the message across to clinicians
Pharma should keep clinicians abreast of transformational change that is happening in their area and make sure their customers are consulted on it. By ensuring its proposals are in line with the NHS England guidance and gathering as much clinical evidence as possible about the benefits of a new drug or service, pharma can then demonstrate how it could add value to the transformation process.
Clinicians are very disease-orientated, so for them the direct impact of a drug on patients, such as its ability to reduce side effects, is the overriding priority. However, such benefits are unlikely to be sufficient to convince commissioners to invest in a product since they are under pressure to deliver on much wider priorities, such as reducing the burden on A&E and on hospitals generally.
Pharma must, therefore, help clinicians to understand the wider benefits that a drug could bring across the whole patient pathway even outside a specific disease area. For example, it could be argued that a product that relieves night-time nocturia will not only improve life for the patient, but also save the NHS money in the long-run. This is because getting out of bed in the middle of the night to go to the toilet is a common cause of falls among the frail and elderly – a problem which can then lead to A&E visits or other NHS treatment. By helping clinicians link the value proposition for a night-time nocturia drug to the Frail and Elderly agenda, pharma could enable them to make a much stronger case to commissioners.
Keeping people out of hospital is another priority that could be addressed as part of the case for a transformational product. So, for example, if a drug does not require administration, surveillance and management in hospital, and can be managed in a primary care setting instead, these are major selling points. Other benefits that are likely to resonate with commissioners are drugs that promote faster recovery by preventing disease complications, and drugs and services that support the self-care agenda.
Engaging with other key stakeholders
Having the right evidence base and framing the right messages in the right way to the right clinicians is a key step. However, pharma also needs to engage with other key stakeholders involved in transformational change and ensure that its value proposition is tailored according to local budgets and priorities as well as national ones.
This should involve developing messaging for the most senior NHS executives who are potentially focusing on four to five priorities, such as reducing pressure on A&E, the frail and elderly, or chaotic families. Industry should also refine its proposition for transformation leads, medicines management staff and other key opinion leaders (KOLs).
It should also be noted that former low-mid ranking CCG commissioners and project managers have transferred across into the integrated care provider alliance, where they have taken up roles such as service improvement managers; hence they are prime pharma targets.
Facilitating engagement between key stakeholders
There is also a role for pharma to play in assisting transformation leads within the Integrated Care System, or STP, to engage more widely within the NHS, particularly clinicians. This is especially important at a micro level where pharma can help to ensure that transformation leads get changes signed off by the relevant parties, so that when they are rolled out, clinicians are fully on board and ready to implement them.
Networking between transformation leads, commissioners, service development managers and clinicians is vital and if it is done well it speeds up conversations, enables shortcuts, and helps change to happen faster and be shared more widely. While organisations, such as Wilmington Healthcare, help to facilitate these kinds of conversations through their networking events, often there is not a formal structure in place to facilitate the process across the wider range of relevant stakeholders.
This is a key area where pharma can step in and get its customers, e.g. consultants and GPs, together to help them understand NHS transformation. Pharma could also offer to help transformation leads bring relevant stakeholders, such as clinicians and multiservice providers,together to better understand change and manage pathways.
Transformation is key to helping the NHS become sustainable and it is beginning to occur in pockets within the service. However, there is a risk that front-line clinicians, who should be instigating and driving service change, are being left out of the initiation and assurance process.
There is a big opportunity for pharma to activate clinicians within service change by making them aware of what is happening in their area and ensuring they understand the wider benefits of a new drug or service from both their own and a wider commissioning/transformation perspective.
Pharma can also take a lead in facilitating discussions between clinicians, transformation leads, medicines management staff and other key stakeholders/opinion leaders to help them better understand each other’s needs and priorities, and to ensure that proposals really will deliver the greatest possible value to the NHS.
Steve How, Paul Midgley and Oli Hudson are all part of Wilmington Healthcare’s Consulting Team. For information on Wilmington Healthcare, log on to www.wilmingtonhealthcare.com
