Made for each other

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Is there anything more tragic than a pair of lovers doomed never to meet? Graham Atkinson makes the case for a money-saving marriage of medicine optimisation teams and commissioners. 

Like two individuals who are perfectly suited to each other but are living in separate apartments in the same building, commissioning and medicines optimisation have lived apart for too long.

They pass each other daily but don’t ever see how attractive they are to each other. It will take the intervention of an observant friend to bring them together. That friend could be the pharmaceutical industry, as nobody else seems to be able to see the potential of a beautiful relationship. In the majority of PCTs, the medicines management function was operated quite separately from commissioning and other core management functions. This resulted in a relatively poor understanding of medicines management activities amongst the commissioning staff responsible for the majority of NHS services. Similarly, most medicines management staff didn’t develop a good understanding of core commissioning and contracting functions. This separation of functions has largely been continued within CCGs, and in many cases has been made worse as the medicines optimisation teams are situated in CSUs, away from the commissioners.

Pressure to perform

Over the next 5-10 years the wider economy – and the NHS in particular – is being challenged to do more with less until we can invest more cash in public services.

The NHS QIPP programme, or a Call to Action as it is being rebranded, requires the service to manage a 4% annual growth in demand with no increase in resources for the foreseeable future. Th e scale of the challenge, to accommodate £50 billion of additional healthcare demand between 2010 and 2020 with no additional resources, is one that even the most efficient of private sector companies would struggle to deliver.

The NHS has faced challenges before, but the tried and tested approaches will not be enough this time; new and more ambitious approaches will be required. The QIPP programme will only be delivered through transformational changes to NHS services, which will require radically different thinking from NHS leaders and front line clinicians.

Transactional change will not even come close to delivering what is needed, and in any case almost all of the transactional opportunities have been exhausted. As Einstein once said, “you can’t solve a problem using the same thinking that created it”. If he were commenting on today’s NHS, he might say you can’t solve a £50 billion problem by using £20 million thinking.

What’s the excuse?

The NHS does not have a good track record of delivering significant cost savings programmes, and has a poor record of delivering transformational change. The recent NHS organisational changes have muddied the waters to the point where individual commissioning organisations are not able to lead transformational change on their own and individual provider organisations are not incentivised to transform their services. There are too many players on the pitch, with too many coaches and critics shouting from the sidelines.

QIPP programmes throughout the NHS require the medicines optimisation team to focus largely on delivering savings in the prescribing budget. During 2013, NHS England reduced CCG budgets due to cost pressures on specialised commissioning, placing additional pressure on the prescribing budgets to deliver further savings. Most medicines optimisation teams are focusing their efforts on cost saving at the expense of improving quality.

The concept of invest-to-save was widely used by PCTs to deliver recurrent savings in future years by investing in service changes in the current year. Investing to save has become much more difficult to deliver since 2010, as reduced cash growth in NHS budgets has required the delivery of savings within the same year of investment.

Saving in the same year as you invest is more difficult to achieve and requires a careful alignment of both commissioner and provider incentives, with tight financial planning and contractual agreements.

In today’s NHS, the pressure to reduce prescribing costs has meant that there has been little or no opportunity to consider investing in medicines to save resources in other budgets. There is a deficiency in thinking and planning in the NHS that fails to connect the opportunities to invest resources in medicines to save even greater resources in services. The separation of medicines optimisation from commissioning is compounded by a silo approach to service budgets within the NHS. The interests of individual provider teams or whole organisations frequently prevent the movement of resources between budgets.

Wanted: Match-maker

For many years, health economists have produced models that show it is possible to invest resources in medicines in order to reduce the demand for associated services. There are many examples of health economic models that describe reductions in secondary care activity that resulted from the introduction of a new pharmaceutical product. Similarly, NICE guidance has been issued outlining where commissioners can make savings by investing in evidence-based treatments. It is also true that very few commissioners have ever managed to realise the savings promised by these investments and interventions.

When a particular investment fails to deliver savings it would be normal to blame the investment, but a failure to deliver savings and services is usually caused by a failure to plan to reduce the costs of the services in the first place.

 

The opportunity remains to invest in pharmaceutical products to deliver savings in secondary care services following a reduction in exacerbations, non-elective activity or the referrals of patients. The evidence base and the health economic modelling are in place – all that is required is a joined up approach between medicines optimisation teams and the commissioners responsible for commissioning hospital and other specialist services. The removal of the silo commissioning mindset would make it possible to invest in medicines by increasing prescribing budgets even in the current climate, having taken resources away from secondary care service lines.

The removal of the silo mindset also needs to span organisations. The recent changes in commissioning structures have, in many cases, further separated medicines optimisation teams from the commissioners responsible for commissioning acute care, which presents a significant obstacle to be overcome in order to promote invest-to-save opportunities with pharmaceutical products. The pharmaceutical industry is well placed to challenge the silo mentality within and across the new commissioning organisations by providing support services to both commissioners and medicines optimisation teams who may be struggling to connect their respective disciplines.

The NHS is running out of ideas and the stage is set for the entry of a new commissioning mindset. There is an alarming gap in both national policy and the delivery of local QIPP programs that have consistently failed to connect the commissioning and pharmaceutical agendas. What is needed is a brave approach from a new direction to fill the vacuum at the centre of NHS delivery. Our lonely NHS spinster and bachelor will need some encouragement and support to fill the vacuum.

 

The pharmaceutical industry will need to develop some new skills to enable effective partnership working in the new NHS. Above all else is the need to craft the value propositions to meet the needs of the customers, including CCGs, medicines optimisation teams and providers. Success will depend on the ability to understand the national policies, know the local priorities and provide solutions to the biggest problems within each area.

A final piece of advice for effective matchmaking and partnering; remember the priority is the services and support you provide, your products come later. So go out there and find those lonely NHS commissioners and medicines optimisation teams – in a few years time they may just invite you to the wedding!

Meet Graham! Graham Atkinson is Director of Transformation and Commissioning at Soar Beyond, working with a range of NHS and private sector partners, both commissioners and providers, to maximise transformational change opportunities. He has over ten years of experience as a commissioner with the NHS, and most recently (2011-13) worked for the NHS Commissioning Board as a transitional director, supporting the introduction of the new NHS commissioning system in England. A pharmacist by profession, Graham is uniquely positioned to understand the commissioning landscape of the NHS and highlight the opportunities for collaborators from outside the industry.

 

Read more about Graham’s work at www.soarbeyond.co.uk.