The NHS in England has undergone rapid structural change in recent years as new models of care developed by Vanguards have paved the way for the emergence of Integrated Care Systems (ICSs) in some areas. These have evolved from Sustainability and Transformation Partnerships (STPs) to take the lead in planning and commissioning care for their populations and providing system leadership.
The changes, which followed the publication of the Five Year Forward View towards the end of 2014, have resulted in an increasingly complex, multi-layered healthcare system that is seeing some GPs taking on wide-ranging responsibilities in ICS areas.
It has also resulted in a diverse range of stakeholders becoming involved in NHS service planning, with local authority officers taking on some key STP leadership roles, for example, as opposed to clinicians; and the third sector and patient groups becoming increasingly influential.
Shift in GPs’ prescribing power
In days gone by, visits to individual GPs were viewed as an effective sales and marketing channel for pharma. However, this is often no longer the case since many GP surgeries now work collaboratively in networks or hubs, which may have a prescribing arrangement across a Federation, a CCG, an STP or even across multiple STPs.
The knock-on effect is that some GPs have grown more influential as they have assumed extra responsibilities following the structural changes. For example, some GPs are now doubling up as the clinical lead for a key disease area, such as diabetes, within their Clinical Commissioning Group (CCG) and, if their locality is the lead area, they might hold the same role across their STP too.
In order to engage with GPs effectively, pharma needs to define the decision-making power of individual GPs. It also needs to know of any pressures that exist to prescribe in a certain way within a network or hub; what formularies they are on and the size of their local Area Prescribing Committee (APC) footprint.
Based on this knowledge, pharma then needs to segment its key GP customer groups and ensure that it is delivering the appropriate message and deploying the right level of resource to each type of GP. This should involve assigning one senior level executive to manage the relationship with a particularly influential GP.
Group consensus is key for STPs
STPs, which cover 44 areas in England, were introduced to build on the work of the Vanguards and implement a place-based care system that incorporates both health and social care. Improving disease prevention, managing avoidable demand and reducing unwarranted variation in care are among their chief objectives, within capped budgets.
Collaborative working is key to achieving these goals and STPs are expected to deliver effective, collective decision-making and governance structures aligned with the accountabilities of their constituent NHS & social care bodies. To this end, they encompass a variety of stakeholders ranging from representatives of Academic Health Science Networks (AHSNs), clinicians and pharmacists to local authority officers, charities and patient groups. Indeed, many local authority officers hold key posts in STPs as well as clinicians. These stakeholders attend key decision-making meetings and group consensus is often required in many STP areas before any significant changes can be implemented.
Some of these stakeholders are new to pharma and in order to engage with them the industry must do more than simply sell products – it must gain their trust in its shared values and philosophy. It must also demonstrate that it is not simply a drug manufacturer; it has a huge amount of expertise in specific diseases and therapies and can lend support in areas such as providing real-world evidence to inform patient pathway development and optimal care.
Medicines management staff within the locality may be involved in workstream planning groups led by programme managers to design new care pathways. They are very much involved in decision-making, however, they work as part of a team, considering the whole implications of care and cost across the pathway.
If a medicine or technology is transformative and can change the way that services are delivered by, for example, helping to move care out of hospitals and developing optimal pathways, then pharma must engage higher up the chain in the STP hierarchy, with people such as programme managers and executive and clinical workstream leads.
Interestingly, the latest NHS Planning Guidance 2018-19, indicates there may be more room for transformative pathways including medicines with STPs, as the system control total eases the history of tension and disagreement over NHS Trusts’ budgetary accountability to NHS Improvement and CCGs’ budget accountability to NHS England.
According to the guidance, there is likely to be a move towards STPs supporting the management of a control total across all parties This means that a hospital could be allowed to spend more on treatments if it means lower costs in outpatient services or readmissions downstream, as long as the total cost in the system is reduced. This is very important for pharma as real-world pathway analysis could mean that expensive treatments may be used earlier in the pathway to reduce the total cost of care.
Integrated Care Systems (ICSs)
Integrated care systems (ICSs) bring together NHS providers, commissioners and local authorities to work in partnership in improving health and care in their area. They will take the lead in planning and delivering care for their populations and providing system leadership.
Key decision-makers in ICSs will grow out of STPs, Vanguards and other new care models such as primary and acute care systems (PACS) and multi-specialty community providers (MCPs), which both seek to integrate care and improve population health. PACS and MCPs take different forms in different places but share a focus on places and populations rather than organisations.
A lot of service improvement managers currently employed by Clinical Commissioning Groups (CCGs) may transition over to work on the provider side in ICSs to ensure transformation happens, or they may work in an alliance within the ICS. A similar situation is likely to occur with middle managers in CCGs while senior commissioning managers and executive managers may take on new roles as strategic commissioners within CCGs or STPs. These changes are going to happen immediately in the areas designated to become ICSs because they must have a structure in place by April 1 to deliver the new ICS care model.
In terms of engagement, it is currently a complex and changing picture for pharma with different levels of development in different areas. The way in which services are planned will depend on a variety of factors ranging from what has happened in the past and what facilities are currently available to who is in charge, and whether it is an urban or rural location. Keeping a close watch on the developments in each locality will be key and will require cutting-edge Customer Relationship Management (CRM) tools, combined with effective real-time insight feeds to analyse the impact of changes.
The complexity and speed of change in the NHS in England has been immense during the past few years and this trend continues apace in 2018. As the NHS puts its faith in new care models that focus on place-based care, populations, systems and collaborative decision-making, pharma must evolve too.
This will involve keeping abreast of new care models that are emerging in different areas across England, being mindful of the variety of responsibilities that key customers hold and taking a tailored approach to engagement across different geographical areas and with individual clinicians.
Pharma must also sell its company and its philosophy to other key stakeholders, such as local authority officers, the third sector and patient groups, and keep abreast of their activities in relevant disease and therapy areas.
Paul Midgley is director of NHS insight, Sue Thomas is CEO of the Commissioning excellence directorate, Steve How is business development director and Oli Hudson is content director, all at Wilmington Healthcare. For information on Wilmington Healthcare, log on to www.wilmingtonhealthcare.com
