Posts Tagged ‘nhs’

Are we going back to the “bad old days” with the most innovative NHS services?

Posted on: March 30th, 2022 by Tomas White

The measures embodied in the Health and Care Bill are seen as the reversal of Andrew Lansley’s 2012 reforms.  It’s therefore unsurprising that Lord Lansley has had much to say about the Bill, making over twenty speeches on the legislation since it arrived in the Lords.

On the topic of specialised services, he has raised the spectre of the “bad old days” where there were “considerable disparities and consistencies” between services. As Lansley put it, his approach in 2012 aimed to “level-up” services in this area by making sure standards were consistent. Whether or not this was achieved, a number of Lords have joined Lansley in making their concerns known, making this a major subject of debate over the past few months of the Bill’s passage.

But to start with, what actually are specialised services and why do they matter? The term ‘specialised services’ hides the fact that actually, some of the diseases, conditions and treatments covered by this style of commissioning are far from rare, or that this part of the NHS is somehow small.

Specialised Commissioning covers 146 services, from conditions as diverse as blood borne viruses like hepatitis C and HIV, which affect hundreds of thousands of people, to treatment for liver and pancreatic cancers which together kill 15,000 people each year in the UK.  When you run through the list of conditions, you realise how important these services are for the people under their care and why finding the perfect formula to structure these services is both so important, and such a challenge.

On the issue of size, it’s worth noting that specialised services now make up a sixth of the NHS’s budget. In the five years to 2020, its budget rose by an average of 8 per cent per year.

Whilst it is the case that the 2012 reforms helped reduce disparities in the care patients received and their access to specialised expertise, they still clearly exist. For example, the recent GIRFT Rheumatology report said that while the current model for commissioning specialised rheumatology services “is working well in some areas” in others, there has been little change to the informal model which existed before. These services are meant to cover rare and complex diseases like systemic vasculitis which have “a much higher risk of mortality and morbidity than more common conditions”.

Meanwhile, on specialised asthma services, the GIRFT Respiratory report said there is “confusion” with some specialised centres not meeting the required criteria.  Again, getting commissioning right here is vital, given large numbers of asthma deaths are preventable.

Now though, a portion of the budget for specialised services is set to be delegated to Integrated Care Boards (ICBs), the NHS bodies which will commission services for areas covering about 1-2 million people, and it’s envisaged that ICBs will either organise provision as an individual ICB, or with other ICBs.  However, NHS England has said that while ICBs will take on the commissioning of some specialised services, “national standards and access policies” will remain. Other services, such as highly specialised services will remain directly commissioned by NHS England. Still, the changes raise a number of questions: Which services will be delegated?  If keeping national policies in place looks to be the strategy to prevent disparities, what happens when, inevitably, services in one area do not meet the national standards, or the standards in other areas?

Specialised services were subject to a National Audit Office report in 2016. The current reforms seek to address some of the wider concerns in that report. For example, the NAO highlighted that patients felt their care was becoming disjointed between specialised and non-specialised services. In addition, over 70 per cent of Clinical Commissioning Groups surveyed by the NAO supported a more joined up approached to services.

Disjointed care is not just an inconvenience. Research in the US, for example, showed that lupus patients with more fragmented care are more likely to develop serious infections and kidney damage. The barriers uncoordinated care creates can exacerbate inequalities as patients have to fight the system to get the care they need. Giving responsibility for specialised services to ICBs, could ensure more coordination, with a ‘bottom-up’ commissioning structure meaning specialised services are more integrated into secondary care and commissioning decisions are made more precisely on local need.

Another of the NAO’s recommendations was for NHS England to develop an overarching strategy and “communicate this clearly to stakeholders”. The number of Lords raising concerns about specialised services in recent weeks is a sign it has not yet succeeded in doing this. For example, Baroness Neuberger, who is also chair of University College London Hospitals Foundation Trust – a major specialised provider (and therefore a major stakeholder) – warned that delegating responsibility “where there is no evidence base for joining up pathways” will lead to more fragmentation and increased costs.

The diseases covered by specialised services include conditions where outcomes have historically failed to improve, like pancreatic cancer, or where current standard treatments remain inadequate. Wonkish discussion of ‘specialised commissioning’, hides the very real consequences that getting this aspect of NHS reforms wrong would have for some of those patients in the most need.

Reducing inequalities in health. How can industry support the new Office for Health Improvement?

Posted on: September 6th, 2021 by Tomas White

On Friday 3rd September it was announced that Secretary of State Sajid Javid had given the go-ahead for the new Office for Heath Improvement and Disparities to launch on the 1st October. As his predecessor Matt Hancock was synonymous with digital and e-health, sources suggest that Mr Javid  is keen to make health inequalities and disparities a main focus of his tenure, perhaps reflecting his position as the first BAME Secretary of State in that Department.

As well as being a personal area of interest, the investment in health inequalities also fits very well with Chief Medical Officer Chris Whitty’s interest in deprivation and its impact on public health (with the CMO believing we can’t solve issues of public health in England without addressing underlying poverty and health inequalities such as access to services). It also supports No. 10’s wider ‘Levelling Up’ agenda. But as with all new agendas, success will be born from partnership with patient, academic and private sectors, so what might the ‘ask’ of the life sciences industry be in meeting the Department’s new priorities?

COVID-19 has shone a light on just how stark health inequalities are in the UK with individuals from black and minority ethnic groups, poorer socioeconomic backgrounds, deprived locations, and vulnerable groups of society suffering the full force of its effects.

But inequalities in health have existed for many decades and have led to unjust consequences in morbidity and mortality. Life expectancy is a key measure of how healthy a society is: and so inequality in life expectancy or quality of life are key measures of health inequality. In England, there is a systemic relationship between how rich you are and your life expectancy. Men living in the least deprived areas can expect to life 9 years longer than their counterparts in the poorest areas. Inequalities in both healthy life expectancy and disability-free life expectancy are even wider than inequalities in life expectancy.

People in poorer areas spend a far greater part of their already far shorter lives in poor health. The sad fact is that inequalities in health, or future health, begin in utero: higher incidence low birthweight, premature birth, infant mortality and cognitive problems are associated with poor maternal health and deprivation. Evidence shows that a quarter of deaths under the age of 1 could be avoided if we had no health inequalities.

Reducing health inequalities and giving everyone the chance of a positive, healthy life is not just a health or an ethical issue, it makes fiscal sense. As noted in the DHSC release, ill-health amongst working-age people alone costs the economy around £100 billion a year, and it’s estimated that 40% of health care provision in the UK is being used to manage potentially preventable conditions.

So the challenge is clear, but what’s the solution and what could the role of the life sciences sector be in helping all patients, regardless of postcode, get the best chance of a healthier life?

  1. Understand the full extent of the problem. Pharmaceutical communications has, rightly so, become far more patient-centric and based on the lived experiences of real patients. But which patients do we hear from most? Arguably those who are engaged, educated and already part of patient communities. We hear from patients who can articulately describe their experience, who challenge the care they receive and know how to ask for more. I personally hate the term ‘hard to reach’, but industry would do well to listen to a broader choir of voices to fully understand how deprivation impacts the ability to get the best care.
  2. Take the path less trodden. So much of our work is London- or major city centric, whether that be working with specialist centres or the media. Researchers from the Massachusetts Institute of Technology (MIT) have found that residing in a city actually adds an extra year to someone’s life. But what about the 25 per cent of the UK that live in rural areas? What about the patient who can’t drive to a specialist centre or knows about the clinical trial currently running?  Industry could focus more outside of its geographical comfort zone to speak to a greater (and arguably more needing) percentage of the population.
  3. Be authentic. Instead of trying to tackle the whole problem, companies need to be able to articulate what their heritage and commitment to reducing health inequalities has been and consider carefully what further value they can add to their patient communities. HSBC, in response to the country’s homelessness crisis, has released a bank account specifically designed for people without a permanent address. Here is a company designing an innovative solution to an established problem in a way which draws upon their expertise. Pharmaceutical companies would do well to think about where they can have the greatest impact, vs trying to impact the greatest number of people.

In summary, industry should be thinking about how to articulate its commitment to meeting the government’s agenda, to improve patient care and outcomes. Pharma has arguably done more than most to understand health inequalities; now that this matches to the government’s agenda so clearly, how can we ensure that the industry’s voice is heard and we are seen as part of the solution? The key will be getting on the front foot and showing Government how the sector has been leading the way vs. waiting to be asked, or even worse, told. In the same way that ‘innovative medicines’ and ‘health technology’ were the focus under Hancock, we now will be asked to answer a different exam question.

The industry needs to evolve its approach in order to answer it.