Creating shared responsibility for healthcare

James Roach on shared responsibility for healthcare

How NHS England is engaging patients in the shared responsibility for their own healthcare by striving to change consumer behaviour.

It could be argued that, following the publication in November 2017 of ‘NHS England’s Items which should not be routinely prescribed in primary care: Consultation report of Findings’, a lot has changed. The concept of getting people to recognise and acknowledge the finite nature of NHS resources, and change their behaviour as ‘consumers’ accordingly, is gaining traction.

The national consultation behind the report has given clinical commissioning groups (CCGs) licence to increase their retreat from prescribing non-prescription drugs. Items available over the counter that alleviate symptoms and are considered common ground for reducing cost, time pressures on GPs and engaging with the public on the ‘shared responsibility’ of providing for their healthcare needs. This is a concept at the heart of the NHS Long Term Plan (LTP).

Back in 2017, NHS England’s report showed the extent to which participants agreed with the proposals to restrict the prescribing of over the counter medicines (OTC). Overall, 50% of members of the public agreed. Of course, obtaining agreement with a proposal among half of respondents – or even a percentage or two more – is not a guarantee of unfaltering traction; the EU referendum the year before is testament to that.

“Creating behavioural change cannot be achieved by impediment, however, making a lasting difference can be secured by enabling people to design their way toward a new behaviour”

Pre-NHS

Looking back to a time before the NHS, the Victorian era offers an interesting insight on the public perspective of purchasing OTC.

Poverty was high, illness stalked all from the very young to the very old, public health schemes were nascent, and getting the services of a doctor came at a price; all too often one that was not affordable to the many. However, seeing a ‘chemist’ was free and most Victorians got their medicines over the counter.

Nobody would advocate a return to the conditions or system of healthcare that existed pre-1948, but the common thread is affordability. The NHS provides a ‘free at the point of use’ healthcare system, but we are all financial stakeholders with the costs pooled across a subscriber base of taxpayers. Affordability is still a central issue and the demands of sustaining the NHS represents an increasing financial tariff on everyone’s pocket.

Each year, around £569m is spent on prescriptions for medicines which could be purchased over the counter from a pharmacy and other outlets such as supermarkets1.

Clinical commissioners are forging initiatives to reduce this spend and time-burden and engaging with their communities to do so in the most effective and appropriate ways. The LTP offers commissioners and communities the headroom to improve further this area of unnecessary cost.  Its pledge is to ‘reduce the prescribing of low clinical value medicines and items which are readily available over the counter to save over £200m a year.’ Somewhat short of the current spend but savings in plans are seldom savings at the bank. However, it is the rumble of traction and a move forward.

Just as the Voluntary Scheme for Branded Medicines Pricing and Access will allow best-value drugs to be fast-tracked through the approval process and provide up to £1bn of savings; the increasing place of OTC in the marketplace continues to grow. The OTC market currently stands at around £2.6bn2.

Pain relief remains the highest value category-group, however, gastroenterology and eye care products have seen one of the largest increases. Replicating growth in the OTC pain relief market across other category groups is a sought-after goal and it’s one made clearer and more opportunistic as a result of the LTP.

Joining forces

The LTP aims to bring down the walls between primary care and community health. This is supported by a population-based approach in primary care and the creation of Primary Care Networks (PCNs).

The new landscape, underwritten by £4.5bn of new investment for expanded community multidisciplinary teams, aligned with new PCNs of neighbouring GP practices, will cover populations of between 30,000-50,000 people. In practice, this will mean:

  • GP practices in a network contract, an extension of their current contract
  • Designated single fund through which all network resources will flow
  • Expanded neighbourhood teams will include GPs, pharmacists, district nurses, community geriatricians, dementia workers and allied health professions, for example physiotherapists, podiatrists/chiropodists, joined by social care and the voluntary sector.

PCNs will have access to a ‘shared savings scheme’ linked to reductions in hospital activity, such as A&E attendances, avoidable outpatient activity and delayed hospital discharges. This could also embrace savings from medicines management.

Working in partnership & adding value

A significant change within the PCN model is the increase in clinical pharmacists in primary care; by seeing patients face-to-face and reducing polypharmacy, they will be key to improving outcomes and reducing admissions from adverse events. They will shape the outlook on reducing the prescribing of OTC medicines.

Agent of change

The LTP is not a magic bullet for primary care. Emerging PCNs will still have to solve the same problem that is the GPs’ daily mathematics seen in the diagram below. The LTP aims to offer a framework within which efficiencies and innovation can be managed that, in turn, operate on supply and demand. Shifting up the gears in the reduction of demand requires a concerted effort across all stakeholders – commissioners, clinicians, communities and industry – to engage with the public on the concept of ‘shared responsibility’. Historically, the NHS outlook on patients taking a greater share in healthcare has focused on getting them to stop doing something. That is not sharing, that is just didactism. Creating behavioural change cannot be achieved by impediment, however, making a lasting difference can be secured by enabling people to design their way toward a new behaviour.

The new PCNs are incentivised by a shared savings scheme; this needs to bring a dividend for patients too. Not just reinvested savings for new services, but benefits that register with local people within their experience of the PCN offer. Pharma can be a real agent of change here. In moving the OTC medicine plan off the page, pharma is well placed to support primary care and the public in designing a new model of engagement with medicines management.

Shared relationship

Much work already takes place among commissioners and providers; information campaigns are common but a poster in a GP waiting room or a flurry of digital messages will not secure enduring involvement with, and participation in, co-owned change. Relationships are the key; the networked gearing in the new primary care model provides opportunities for the very players with whom pharma already has the relationships.

It is clear that the LTP intends to free up both time and resource; time spent looking after the patients with the greatest need, and resource reinvested in innovation and the transformation of services. Supporting the system means getting closer to the people and sharing in the relationship between clinician and patient.

Whatever challenges exist for pharma, be it those related to Brexit, or domestic issues like a possible return to the hub and spoke dispensing model, the LTP provides the opportunity to align with the NHS’ growing ambition for sustainability and affordability and to collaborate with NHS commissioners and providers at scale – but in a condensed way. Initiatives that support this will be well-received.

James Roach is Director of Conclusio Limited. Email jamesprroach@yahoo.co.uk