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Hitting the ground running: The first 100 days
Hitting the ground running: The first 100 days

Archive for the ‘NHS’ Category

Navigating party priorities: health policy in the political landscape

With Party Conference Season now behind us, we have (some) more clarity on the health priorities of the two major political parties. Now that both the Labour and Conservatives have established their positions, what does this mean for organisations seeking to engage on the commitments made by both sides, as competing priorities divide attention?

In this analysis we show how healthcare organisations can amplify their policy objectives with Government and the Opposition through shared ambitions, as Westminster gears up for a general election.

Prevention is the name of the game

Your policy positions need to align to the prevention agenda.

While political championing of prevention is not new, one of the clear shifts for both parties this year was the central focus on public health and prevention.

For the Conservative Party this is a significant change in direction, fronted by the smoking ban announcement made by Rishi Sunak on the final day of conference; arguably, what could be one of the most significant public health interventions of recent decades. This is perhaps not surprising, given it is unlikely that the Government will have met many of its 2019 health manifesto commitments by the general election and hence a desire to show real change.

For Labour, Wes Streeting’s ‘shift from treatment to prevention’ was reiterated throughout conference. Unlike the Conservatives’ approach of bold policy to demonstrate change, Labour’s position is focused on long-term planning. However, despite talk of 10-year strategies and the shift towards community-centric care, many were left questioning the practicalities of implementation including the rebalancing of investments and community staffing.

Crafting effective policy asks

Your policy asks must focus on levers that can enact change and drive impact.

While ambitious reforms may capture attention, policy teams in Government and the Opposition are facing competing priorities with limited resources.

Wes Streeting has reiterated this distinction, favouring detail and evidence over ‘pledge card policies’. This is especially important to bear in mind when engaging with Labour. Also, while Streeting may have presented his overarching goals in Labour’s Health Mission, his shadow ministers are still getting to grips with the intricate details of their briefs.

It is nuanced and well-articulated policies that will hold weight for Labour and the Conservatives in the run-up to the general election. This means an opportunity to engage constructively by offering expertise, insights, and data that can inform policy decisions. Organisations should invest in refining their precise policy asks that address the current real-world challenges, and where possible, costed roadmaps for implementation.

In it for the long haul

Focus on policy proposals that can unlock cash or productivity

What is abundantly clear is that both parties are positioning their priorities as long-term commitments and ambitions.

For both, this is in part necessity – with reluctance to commit to any new policy proposals for fear they could be held up as uncosted. The other part is about positioning, with parties wanting to be seen as the safe bet for the future. This pivot will arguably be harder to pull off for the Conservatives who have been at the helm for more than a decade. For Labour, it may suggest short term inertia if elected, with fiscal restraint likely to remain front and centre in the first 12-18 months.

For organisations looking to engage with the health policy agenda is greater scrutiny on the financial implications of policy proposals. Political and policy prioritisation is likely to be focused on interventions that can either unlock cash or create an immediate and measurable impact on productivity to unlock capacity in other parts of the system. Engagement should focus on being explicit about where these savings can be made.

About WA Communications

WA Communications is an integrated strategic communications and public affairs consultancy. Our specialist health practice supports clients across a diverse range of diseases at the intersection of policy, government affairs and communications, to achieve their strategic objectives.

If you would like to discuss how we can help your key areas of focus, contact Giulia Corsi at giuliacorsi@wacomms.co.uk.

Our analysis of the Labour Party’s health policy thinking draws Next Left – WA’s recently published Guide to Engaging with the Labour Party – which explores the people, processes and politics shaping the development of Labour’s next election manifesto, and how businesses in every sector can engage with the party’s plans.

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Five key takeaways: Engaging with ICS priorities panel session

WA was delighted to host a panel session with Dr Layla McCay, Director of Policy and NHS Confederation and Mike Bell, Chair of NHS South West London integrated care board (ICB) and WA Health Senior Adviser.  

At the session, WA’s Head of Health, Dean Sowman, explored Layla and Mike’s perspectives on how the life sciences industry can meaningfully engage with, and play a role in delivering integrated care systems (ICS) priorities. 

In light of a 30% cut to operating budgets and industrial action absorbing the bandwidth of executive teams, ICSs are currently heavily focused on short-term operational priorities. We have outlined five key factors to engage effectively against this backdrop:   

1. ICSs are delaying some action until the general election 

Whilst both the Labour and Conservative parties have communicated support and optimism for ICSs, the reality is that political uncertainty and operational pressures mean that many ICBs have little bandwidth to implement their ICB led five-year joint forward plan.  

Instead, ICSs are increasingly deferring important decisions until there is a stable administration which can ensure the preservation of essential funding and objectives. The overarching concern is that the exact vision of ICS working to respond to local population needs will be overshadowed by national pressures.    

Whilst this is a considerable challenge, the take home message for organisations looking to engage is the importance of timing the hope is that following the winter period, which is a particularly politically sensitive time, ICSs will have greater bandwidth to begin to implement their strategies.  

2. There’s no shortcut to engaging with all ICSs, and no one-size fits all approach 

When looking to secure policy changes, there is currently no shortcut to speaking to all 42 ICSs. We are starting to see some ICSs coalescing or developing strategic multi-ICB structures where some ICBs lead on certain workstreams on behalf of others. This trend is likely to become more commonplace – so engagement may become more streamlined in the future.  

For now, the best route to engage with multiple ICSs comes through existing forums, including NHS Confederation’s ICS network and NHSE’s Academic Health Science Networks (AHSN) 

3. Medicines optimisation and management is a priority with positive examples needed  

One key barrier to ensuring medicines optimisation is that current financial models are created to show benefits to local service providers – some of which are not covered by ICS budgets. There needs to be an overhaul of where the service is delivered, where the money flows and where the savings are realised. While there is clarity on this being a problem – at present there is no solution.  

NHS Confederation would welcome examples of impactful collaborations between ICSs and industry as there is currently a shortfall of tangible examples.  

4. New evidence and ideas to support the delegation of specialised commissioning are welcomed  

The delegation of specialised commissioning to ICSs remains a concern. Prescribing budgets will remain with NHS England, but services deemed ready for integration will be delivered locally. There are outstanding questions as to whether individual ICSs are equipped with the right workforce and expertise, and what multi-ICB structures could be formed.  

This is especially pertinent in the case of rare diseases. Given their low prevalence in local areas, rare diseases are unlikely to be a core focus for ICSs, as evidenced by WA’s analysis which found that just five of the ICB five-year plans featured rare diseases.  

However, there is optimism that the transfer of specialised commissioning responsibilities offers the opportunity for a reset. If done right, it could ensure the repurposing of specialised commissioning budgets across the whole pathway, challenging local systems to reduce spend on tertiary services, and instead finding new ways to act earlier.  

5. Understanding where each ICS is placing strategic emphasis is critical 

Each ICS is at a different stage of maturity and there is distinct variation in size, scale and local characteristics, meaning a one-size fits all approach to engagement will not work. As a first step, understanding where you may wish to begin engagement and how to frame this in line with local priorities is essential. 

At the end of June 2023, 40 of the 42 ICBs had published their five-year joint forward plans setting out their strategic vision to tackle the health issues faced by their local population.  

To support industry, WA has undertaken an in-depth analysis of the plans to create an interactive map showing the level of priority each ICB is placing across 27 themes. Understanding the ICBs that are prioritising your areas of interest, can support you in identifying meaningful collaborations and partnerships aligned to an ICB goals. 

About WA Communications 

WA Communications is an integrated strategic communications and public affairs consultancy. Our specialist health practice supports clients across a diverse range of diseases at the intersection of policy, government affairs and communications, to achieve their strategic objectives. 

If you would like to discuss how to best work in partnership with Integrated Care Systems, and our analysis of their key areas of focus, contact Lloyd Tingley atlloydtingley@wacomms.co.uk. 

 

 

 

 

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NHS England’s medicines optimisation guidance: What are the opportunities to improve uptake of medicines at ICS level?

The NHS has been plagued by difficulty when it comes to variation in the uptake of NICE approved medicines. With the establishment of ICSs, there has been an attempt to position medicines as strategic enablers of improved patient outcomes and NHS productivity and efficiencies rather than just a clinical intervention for patients. The publication of NHS England’s medicines optimisation guidance 2023/24 last week signals a shift to create a national framework around this ambition, which NHS England (NHSE) has linked to integrated care board (ICB) priorities. Reading the guidance, the financial imperative is clear the broader goals of medicines optimisation e.g., reduced wastage, improved outcomes, and improved safety, are consistently correlated to helping systems ‘deliver financial balance’. 

However, with financial constraints placed on ICBs and the ongoing operational pressures facing staff, the root perception that medicines optimisation equates to doing more with less must be tackled first.  

NHS England’s new guidance sets out 16 national medicines optimisation opportunities for 2023/24, and signposts to best practice resources to support implementation. NHS England recommends that ICBs choose at least five medicines optimisation opportunities.  

What does Industry need to know and do following publication of this guidance?  

Here are a few of our thoughts: 

As we look to implementation, many questions remain. Will we see ICSs prioritise the same five ‘opportunities’ and what does it mean for progress in the opportunities that are not selected? How should system partners tailor their approach to targeted interventions in each ICS, each with differing local barriers? Finally, what additional strategies can help ensure that healthcare inequalities are not exacerbated? The ambition is high and must be matched by collaborative action at national, regional and local levels.  

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NHS Leader Joins WA Communications Advisory Board

We are pleased to announce the appointment of NHS leader Mike Bell to our growing advisory board. Mike Bell brings a wealth of experience and expertise in the healthcare sector, having served in various senior roles within the NHS.

Mike is currently Chair of NHS South West London Integrated Care Board and Chair of Lewisham & Greenwich NHS Trust.

With over 25 years of NHS board level experience, including more than a decade on strategic health authority boards, including as vice-chair of NHS London, Mike brings a deep understanding of the healthcare landscape to his advisory role. Previously, he served as the Chair of Croydon Health Services NHS Trust, playing a pivotal role in improving healthcare services in the Croydon area.

Our specialist health practice offers integrated services in public affairs, corporate communications, digital, research, and creative services. Current clients include life sciences companies including Sanofi, AbbVie and Roche, as well as charities and patient groups including Guide Dogs and Muscular Dystrophy UK.

Mike Bell’s appointment to the advisory board further strengthens our commitment to providing strategic counsel in the healthcare sector.

WA’s advisory board is chaired by Sir Philip Rutnam – former Permanent Secretary at the Home Office and Department of Transport, and founding Partner of Ofcom. It also draws together senior figures from the communications industry, Westminster, the media, and the health sector, including former CEO of Grayling UK Alison Clarke, and broadcaster & journalist Steve Richards.

Commenting on the appointment, Caroline Gordon, Partner and Head of WA Communications’ health team said,

“I am delighted to welcome Mike to our team. His extensive experience and strategic insight in the NHS and medtech sectors will be invaluable in delivering senior counsel to our clients in health and life sciences. WA is now even better equipped to navigate the complex and changing landscape of healthcare delivery and drive meaningful outcomes for our clients.”

Mike Bell added,

“I am delighted to be joining WA Communications at this exciting time. As a member of WA Communications’ advisory board, I look forward to using my experience from two decades in the healthcare sector to provide strategic guidance that helps clients partner effectively with the NHS.”

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‘Stopping the 8am rush’ – Is the plan for recovering access to primary care an oversimplification?

The primary care access plan is finally here. A comprehensive plan to mull over but difficult to have a full view in the absence of the workforce plan. It is coined by DHSC as “the first step to address the access challenge ahead of longer-term reforms”, but this is not to undersell its transformative potential. Primary Care Networks (PCNs) are now fully focused on delivering this plan which spans the introduction of better phone and online systems, pharmacies supplying medicines for more conditions, and more staff and more appointments – anything else will be deprioritised.  

The plan has been widely praised as championing innovation. However, there is a feeling that the plan doesn’t duly assess the risks and benefits of what has been put forward and is perhaps an oversimplification from DHSC and NHSE.  

On a micro level, in this blog we explore the potential impact on access of changes to the role of pharmacy, the Investment and Impact Fund (IIF) and Quality and Outcomes Framework (QOF).  

Broadening the role of pharmacists presents both opportunities and risks

Pharmacy First has arguably elicited the strongest discourse and feelings both good and bad. Outwardly, a number of high-profile pharmacy leads are supportive of the initiative but there is cautiousness amongst the health sector. In conversation with David Thorne, Transformation Director at Well Up North PCN, he noted the following challenges:

1. Interoperability: It is vital that GP and pharmacy systems speak to each other, and we avoid the fragmentation that has bedevilled GP systems to date. Currently, robust systems are not in place to inform pharmacists of what medication someone is on to support their prescribing decisions ─ apart from placing faith in very early use of the NHS App. We need consistency and safe links, especially when looking to enable people to use a pharmacy distant from their GP practice.

2. Pharmacy closures:  In theory, the enhanced role of pharmacists could make primary care more accessible. However, data reports that pharmacy closures have disproportionally been in the most deprived areas of England ─ so there is a risk that positive changes to the role of pharmacists’ conflict with national priorities around health inequalities. One of the main drivers of the shortages of community pharmacists is the PCN recruitment of pharmacists to work in primary care roles.

3. Right Place, Right Role: Community Pharmacies may not be able to develop responsive clinical governance systems that adequately respond to case mix escalation, for example when superficially routine consultations escalate to issues of drug/alcohol misuse, mental health and safeguarding. How can we support pharmacists to develop the skill, time and governance systems to manage the types of conversations that GPs have?  Extensive training and public awareness will need to accompany these changes.

This is far from a done deal with negotiations on the £645 million supportive investment ongoing. Further, there will be a consultation on upholding patient safety considering greater prescribing powers for pharmacists.

Polling results conducted by WA communications in March 2023 of 1,000 members of the UK public highlight that whilst there is public support for a greater role for pharmacists, there is some way to go to building public awareness of the services pharmacists can provide.

A word of caution surrounding progressive changes to the IIF and QOF

Further details of the streamlining of IIF and QOF were announced within the plan. Redirecting £246 million of IIF funds represents a major shift with 30% to be awarded by ICBs (integrated care board), conditional on PCNs achieving agreed improvement in access and patient experience. DHSC/NHSE guidance is that access improvement plans should prioritise supporting those with the lowest patient satisfaction scores.

Local flexibility must be at the heart of the re-design of incentives, without arbitrary access quotas for certain groups such as ethnic minorities or LGBTQ+, which could lead to under-funding and deepening inequalities. It seems that DHSC/NHSE are cognisant of this, explaining that the plan is designed to move towards a “more equitable approach that will benefit all patients” and “does not call out specific cohort of patients” for that reason. This must be pulled through at an incentive level to ensure certain PCNs such as rural PCNs who may have small numbers of certain communities, are not caught out.

NHSE further announced that, through a consultation this summer, they will explore how to link QOF to key strategies such as the upcoming Major Conditions Strategy. Ultimately, ICBs new commissioning powers will mean ICBs very closely performance manage PCNs. This goes against the ‘neighbourhood’ aspect of integrated care reforms, which will only seek to become more complex as preventative care models are adopted.

As always, implementation will be the true test. The plan comes with no standardisation frameworks or action plans attached. This passes the buck to PCNs and/or ICBs to operationalise, which risks fragmentation in the absence of nationally led advice.

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The challenges that remain for tackling variation in CVD prevention in England

Cardiovascular disease (CVD) is one of the leading causes of morbidity, disability and health inequalities, affecting approximately 6% of the adult population in England.  

To provide greater understanding on the state of CVD prevention services across England, the NHS Benchmarking Network publishes an annual CVDPrevent audit report. The latest iteration is much more oriented to looking through the lens of health inequalities and regional variation in care, highlighting the significant issue of a postcode lottery in cardiovascular care across the country. This new angle of focus of putting inequalities in the spotlight in the CVDPrevent report rightfully signals that this is where the focus should be for both health system leaders and industry working in this space alike.  

The report indicates some positive highlights for example with the prescription of anticoagulation drug therapy for those with atrial fibrillation at high-risk of stroke rising to 88.9% – only 1.1 percentage point below the national ambition to reach 90% by 2029.  

However, there remains some distance to go on the road to recovery from the pandemic with hypertension services particularly lagging behind others and health inequalities and variation remaining prevalent. Notably, individuals from a Black, Asian or Minority Ethnic background were identified as being the least likely to be prescribed an appropriate drug therapy, receive monitoring, or be treated to target with similar issues present across sex, age and deprivation level.   

Alongside variation in treatment and management, there is also significant variation in local approaches to CVD prevention. Our research and analysis of ICS strategies, planning documents and data relating to CVD-prevention, has found that there is a significant level of variation present in the level of planning for CVD prevention services, as well in care and outcomes.  

It is therefore particularly welcome to see the recent prioritisation of CVD services on the national policy agenda through the intention to publish a Major Conditions Strategy later this year and more recently through the appointment of Professor John Deanfield as the first ever Government Champion for Personalised Prevention. Both developments recognise the issue of inequality and unwarranted variation in the absence of a dedicated Health Disparities White Paper.   

However, the test of any such policy is whether it can be implemented uniformly to impact change across the country and not exacerbate variation as well as whether it can truly trickle down and impact at the local place-based level. To do so these policies will need to balance national direction with a sufficient amount of autonomy to allow for population-based CVD prevention strategies, an ambition of newly formed integrated care systems.  

Although the report demonstrates that progress is being made in this hugely important disease area, it is clear to see that much work remains to be done. Promising policies with high potential are a welcome sight to see and only time will tell if they can truly make the impact they set out to achieve.  

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WA Communications roundtable with Rob Kettell

On Thursday 6 October, WA Communications convened a roundtable discussion between Rob Kettell, Director of Commercial Medicines Negotiation and Complex Transactions at NHS England, and representatives from leading pharmaceutical companies.

The session explored NHS England’s Commercial Medicines Directorate (CMD) priorities, and how companies can work in partnership with the NHS to ensure timely access to medicines for patients.

The session was timely, given the recent and further pending changes in the leadership team within the CMD, the recent launch of the innovative medicines fund (IMF), and ahead of discussions about a successor to the voluntary scheme for branded medicines pricing and access (VPAS) that runs to the end of 2023.

To start, Rob outlined his three priorities:

  1. Access: Continuing to secure rapid patient access to new treatments
  2. Uptake: Ensuring there is consistency in the use of innovative treatments that are provided on the NHS across the country.
  3. Value: Delivering value for taxpayers by striking commercial deals for new medicines that are clinically led and commercially driven, at cost effective prices

A wide-ranging discussion followed. We outline five key takeaways below:

  1. Better, earlier dialogue between the NHS, NICE and companies has helped ensure expanded and accelerated access to innovative treatments, and this can continue to develop in the future

The growth of the commercial medicines team and with it the evolution of the commercial capabilities within NHS England has allowed for earlier and greater engagement with industry. Whereas previously, dialogue between NHS England, NICE and companies could be inconsistent and limited, there are now clear and established routes for early and ongoing communication – including a formal triage function in the CMD. This has benefited both sides, and is an approach that NHS England is keen to continue to develop.

As well as supporting new approaches to individual negotiations, it has also led to more effective horizon scanning which, in turn, has helped the CMD to work with NHS colleagues to better plan for new types of medicines, or medicines in specific disease areas, which may be ready to be appraised at the same time. For example, Advanced therapy medicinal products (ATMPs) have been earmarked as a potential priority area for the coming years, building on the NHS’ track record as a leader in Europe for cell and gene therapies

It was acknowledged that this stronger approach to partnership working has been essential in overcoming some of the more difficult recent access challenges. Securing patient access to immuno-oncology treatments and combination therapies are clear examples of cracking ‘unsolvable’ challenges when all parties work together in partnership to ensure rapid access.

NHS England is now keen to work with companies to explore how to signal areas where there is demand for innovation from the system. This can give further clarity to industry on where focus may lie in the future.

  1. A focus on primary care to meet population health needs

Rapid innovation in drug development over the last ten years has led to huge breakthroughs for conditions with high unmet need like cystic fibrosis and spinal muscular atrophy. However, the focus on innovations like gene therapies and precision medicines, which are prescribed and administered in hospital settings, has not been matched by the same focus on innovation in the primary care setting, which is needed to achieve the population health ambitions of the NHS Long Term Plan.

There is now a real appetite to explore how innovative treatments that have an impact on a wider, population-based level, in areas like as cardiovascular disease, can be brought into the system.

This may require new approaches to align value and affordability among very large patient populations. There is appetite for further exploration of how industry and NHS England can work together to find access routes for more to patients in primary care – to have the most significant impact.

  1. The CMD is keen to partner with companies to boost uptake, but must be selective

It was acknowledged that progress on boosting the uptake of new medicines has been mixed.  There have been some big successes, particularly on treatments that have benefited from funding through the Cancer Drugs Fund, but also areas where potential uptake has not been realised, or has been slower than it could have been.

NHS England – including the CMD – has finite resource, and current fiscal pressures mean there is more focus than ever on achieving value. It must therefore focus this resource towards areas which are likely to have the biggest impact. This will inevitably require a degree of prioritisation on where to focus attention.

As an example, this might include working more closely with companies on targeted uptake strategies whose treatments address longstanding health inequalities, for example, as aligned with the NHS’ health inequalities CORE20PLUS5 strategy.

  1. The CMD is driven by the need to provide value to the taxpayer across all activity

There is recognition that the pricing and revenue environment in the UK is tighter than some other countries. From an NHS perspective, this provides value to the taxpayer and supports the sustainability of the NHS – while companies benefit from the NHS model where access to more than 55 million people can follow a single successful negotiation.

The NHS commercial framework for new medicines points to the complex problems that the CMD is often trying to solve by agreeing ground-breaking and world-first deals, for example the recently announced antimicrobial subscription model.

There is clearly risk involved in facilitating complex deals that go beyond a simple discount to reach a cost effective price with NICE. Therefore, more value needs to be derived from them, ideally creating a ‘win-win’ for companies, the NHS and the taxpayer.

Value is always expected to be at the cornerstone of all decisions made and can often be generated by treatments sitting at, or below, the bottom end of the NICE QALY cost-effective range. This is the value NHS England expects going into a complex negotiation.

  1. Making the UK an attractive place to launch medicines and bring in research and development investment is a continued area of focus

In recent years, the Life Sciences Vision and the UK’s Industrial Strategy have set-out ambitions to make the UK an attractive location for global pharmaceutical companies to invest in.

Maintaining and building on the opportunities of the UK’s strong skills and science base, regulatory regime, single payer system and high levels of clinical trial activity remain key features in the government’s ambitions for global life sciences leadership.

There is clearly appetite on all sides for the pharmaceutical sector to be a key industry to help deliver the government’s economic agenda. However, industry representatives expressed their views that life sciences investment in the UK could be limited due to the rigorous focus on securing value as outlined above.

While recognising the need for value, a more holistic approach to the life sciences operating environment is becoming increasingly important for industry. There are risks to these growth ambitions if industry feels squeezed on all sides. An elevated – more unified recognition of industry’s contribution would enable UK leadership teams to make a stronger case internally for further investment in the future.

In summary:

  1. Utilise NHS England’s CMD triage function and the Office for Market Access to support with early dialogue and horizon scanning
  2. NHS England would welcome ideas and support to more effectively signal demand to the sector in specific disease areas
  3. Ensure resources are used effectively by providing detailed information and positions to NICE at pre-committee stage
  4. The NHS is looking to tackle the population health challenges set out in the NHS Long Term Plan, including by utilising greater innovation in primary care
  5. Medicines that offer holistic benefits, such as addressing longstanding health inequalities, are more likely to be considered for a bespoke NHS arrangement to drive faster and comprehensive uptake

About WA Communications

WA Communications is an integrated strategic communications and public affairs consultancy. Our specialist health practice supports clients across a diverse range of diseases at the intersection of policy, government affairs and communications, to achieve their strategic objectives.

If you would like to discuss how to best work in partnership with the NHS, contact Lloyd Tingley at lloydtingley@wacomms.co.uk.

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What the new integrated care model means for specialised services

In July this year, the Government passed the long-awaited Health and Care Act 2022. A major part of the legislation was designed to drive integration of local services with the aim of enabling areas to adopt a preventative approach that focuses on population health.

After many years of movement in this direction, 42 Integrated Care Systems (ICSs) were formalised and tasked with bringing local health services together to provide more joined up care. Unlike unpopular health system reforms of the past, the broad consensus is that this reform is both important and progressive. Indeed, this was a reform that NHS England itself had called for.

However, major changes to specialised commissioning have raised concerns. In particular, patient groups have many questions around the impact these changes may have on the day-to-day care of people living with complex conditions.

Previously, NHS England commissioned many specialised services. As a result of the Act, the majority will now be commissioned locally by Integrated Care Boards (ICBs).

But complex conditions need complex care. The move to local commissioning is risky, mainly because a population management approach is not suitable for rare and complex conditions and commissioner expertise may be lost in the transfer.

Against this backdrop, WA Communications has been working with Muscular Dystrophy UK, the charity for the 110,000 people living with muscle-wasting conditions in the UK to understand the situation better.

Together, we’ve been exploring how ICSs should approach their new commissioning responsibilities to ensure people with muscle-wasting conditions receive best-practice care from 2023.

It’s vital that ICSs get this right, so that patients with muscle-wasting conditions experience at least a maintenance, or at best an improvement, in their care.

Our work culminated in a report, based on insights gained through workshops with clinicians and an APPG on Muscular Dystrophy meeting. The report can be accessed here. We identified three key areas that ICSs need to focus on:

  1. Building understanding: Inevitably, ICS commissioners and community clinicians may be less familiar with muscle-wasting conditions than specialist commissioners. However, it is fundamental to the commissioning and provision of good care that there is appropriate understanding of the condition and the level of care required. Finding ways to rapidly boost knowledge must be a priority.
  2. Holistic approach: There is a real opportunity for ICSs to improve care due to their in-built, joined-up approach. This means moving away from a sole focus on medical care to one that includes social care, education, physical activity, all of which takes place closer to home.
  3. Data: High quality and regularly updated data are vital for oversight of the quality of care, service planning and improvements. NHS England could support effective local commissioning through the creation of a data dashboard across ICS regions. This could outline key datasets for muscle-wasting conditions, such as condition prevalence, time and route to diagnosis, mortality, admissions and treatment.

You can download the full report here:

The new integrated care model and muscle-wasting conditions: How Integrated Care Systems can implement best-practice

Change of this nature is never easy, especially in a period of financial constraint and workforce pressures. However, focusing on the opportunities for better, more joint-up care – ideally backed up by robust data – could deliver important outcomes for people with muscle wasting conditions. Because ensuring the best possible integrated care for patients with all complex conditions can only be achieved through collaboration, communication and consistency.

We have been proud to support Muscular Dystrophy UK in this important pro bono project. You can read the full Muscular Dystrophy UK report on The new integrated care model and muscle-wasting conditions: How Integrated Care Systems can implement best practice here. If you are interested in learning more about how we can help you, please get in touch with carolinegordon@wacomms.co.uk

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Like pulling teeth: has the government finally got to grips with dental contract reform?

More than a decade after the coalition government announced its intention to reform the dental contract in England, action may finally be on the horizon. The new Health Secretary Therese Coffey has announced her focus will be on “ABCD: Ambulances, Backlogs of routine treatment, Care, Doctors and Dentistry.” It is no secret that NHS dentistry has been facing a growing crisis, with patients across the country struggling to access treatment due to the number of dentists moving to the private sector. Coffey’s challenge is significant – stabilizing the system and restoring public and professional trust in a system that has seen a number of false starts in the quest for a new dental contract.

The current dental contract has long been criticized by dentists for its sole focus on activity, which reimburses dentists for the volume of activity ‘units’ they complete. Dentists argue that this process is overly simplistic, and prevents them from focusing on preventative treatment, as they are financially incentivized to carry out more invasive work.

To remedy this, in 2015 the coalition government announced the launch of two new prototype contracts, with the aim of reducing dependency on activity as the only means of measuring activity and allocating funding. After the timetable for reform was pushed back repeatedly for a number of years, the government announced it would abandon the protypes in March 2022 and would work to find an alternative means of reform.

Against this backdrop of long term uncertainty, NHS dentistry has struggled to recover from the disruption caused by Covid-19, and is now suffering from an accessibility crisis. Since the pandemic, many practices have been operating at full capacity with patients waiting months for an appointment. At the same time, dentists are leaving the NHS, with over 2,000 ending their NHS contracts in 2021 alone. This leaves those remaining struggling to keep pace with demand. Currently, 90% of dental practices in England are unable to take on new patients, driving patients to the private sector (where they can afford it).

In July 2022 the Johnson government announced some significant revisions to the contract, with the aim of stabilizing NHS dentistry. These changes included establishing a new minimum UDA value, which increases the amount dentists will receive for their work, funding practices to deliver more work where possible and removing some of the barriers preventing dental therapists from carrying out treatment.

The reforms have been largely well received, but some sector leaders have warned that they lack the ambition to truly solve the issues the sector faces. Nigel Edwards, Chief Executive of the Nuffield Trust has argued that ”a lack of investment and misalignment between costs and funding have made it increasingly unattractive to be an NHS dentist. The resulting exodus of dentists has fuelled growing waiting times. While more money to help high-performing dental surgeries see more NHS patients is helpful, it does not address the problem that many areas in England have little or no access to an NHS dentist.” This view is shared by the British Dental Association, which has warned that the changes will not stop the ongoing exodus of staff from NHS dentistry, or solve patient access issues.

We may have already seen some preliminary reform to the dental contract, but Coffey’s very public focus on dentistry as an issue indicates that further reform is on the horizon for the NHS dental sector, an admission of how much change is needed. It also potentially signals that dentistry, long seen as a Cinderella service in comparison to other parts of the health system, may finally be getting the recognition and attention it needs to be able to secure real and lasting change.

In the meantime, however, more dentists are likely to switch their focus to private practice, in turn driving those who can pay for dental treatment to do so. The government is unlikely to seek to alter this dynamic and is likely to instead focus on addressing the lack of NHS dentists taking on new patients to attempt to stem the accessibility crisis.

Solving the issues facing the dental sector is no mean feat, but in putting the issue so high on the political agenda, Therese Coffey has indicated that there is now a feeling of greater urgency in finding a solution to long running issues affecting the sector. Regardless of what this change looks like, demand for affordable, accessible dental care will remain extremely high, particularly for patients who are unwilling and unable to pay high prices for treatment in light of the growing cost of living crisis.

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Stamping out “waste and wokery” – the task at hand for the new NHS Chair

Stamping out “waste and wokery” – the task at hand for the new NHS Chair.

Richard Meddings, a former banker with over 40 years of experience in the financial sector in both public and private sector roles has recently taken over as the new Chair of NHS England. Meddings has been brought in to be watchful over “any waste and wokery” of NHS resources and help deliver the Government’s ambitious agenda of reform for NHS England. The ongoing pressures on the NHS were well documented prior to the pandemic, and concerns over the sustainability of its funding are seldom absent from political discourse. So, is Meddings’ appointment in keeping with Sajid Javid’s ambitions for the NHS in the coming years, who is he, and what can we expect from him?

Who is Richard Meddings?

Those who have worked with him report that he is forensic, exceptionally detailed and pragmatic in his approach to his work. Whilst serving as a Chair at TSB, Meddings was known for navigating them through a turbulent year of crises and restoring public confidence in the bank significantly. It is no surprise these qualities endeared him to Sajid Javid, who sought a skilled operator with experience of reforming and influencing change at the highest levels of business as his ministers have taken a harder stance on holding managers to account for improving services within the NHS.

Others have expressed concern over his lack of experience in the health sector, and the Health and Social Care Select Committee were not unanimous in their decision to appoint him. Meddings countered critics by stating that there was ample sectoral experience in the board already, and his merits would be to bring “to bring fresh insights, strong experience of board governance, digital and financial skills, and courage in adversity and strategic leadership”.

What can we expect from him?

Meddings enters his role with a challenging brief already in front of him. He will quickly have to showcase his understanding of NHS England’s DNA to win over any sceptics in the organisation. Whilst his appointment was unashamedly based on his experience in finance, he will among other things, have to adequately manage the redirection of an expanded workforce back to the day-to-day delivery of services, as well as ensuring NHS boards align with the Government’s wider integrated care ambition.

Overseeing the change from CCGs to ICSs in July will be a significant stress test of his Chairmanship. Across the country several clinicians will end their roles as CCG Chairs, thus creating a large exodus of clinical experience. Without his own established network throughout NHS England, Meddings will have to quickly understand what life is like at the coal face to get an acute sense of the pressures at a local leadership level. Clinicians are typically not engaged in managing systems and overseeing budgets, so in order for Meddings to achieve his ambitions of better managing NHS finances and reducing waiting lists he must ensure that under the new ICS structure they are engaged at all levels of decision-making.

The Government has stated £800m needs to be made in savings across its health departments this calendar year and as such funding for several programmes has been pulled back already. Whilst it seems unlikely that this ambitious target will be met, a more accurate metric of Meddings’ success will be whether he can balance cost savings whilst also producing tangible results for patients.

What does his appointment tell us?

The Government is eager to demonstrate how the NHS can be run cost-effectively, and how it can be reformed to improve the way it works in addressing the significant backlog it continues to face. It is no coincidence that Meddings’ appointment is one of three recent major Government appointments of officials with backgrounds in finance, with Samantha Roberts (formerly at Legal and General) appointed as the Chief Executive of NICE, and Ian Dilks (formerly at PwC) as Chair of the Care Quality Commission. Given the Secretary of State’s previous experience both in finance and in his previous role as Chancellor, it is unsurprising he is looking to those with a history in the financial sector to support the delivery of his ambitious reforms.

His appointment also reminds us that Javid will need to demonstrate to the Chancellor that Meddings is the man who will deliver tangible improvements to NHS England’s efficiency and value for money to substantiate the controversial health and social care levy introduced in April this year.

Measuring success

Meddings’ first year will be critical in defining whether Javid’s gamble to appoint a rank outsider has paid off. Javid’s optimism in the new Chair’s previous experience to address any “waste and wokery” and see through his reforms may be well placed, but Meddings must be careful to ensure that ruthless focus on finances does not come at the expense of patient outcomes and quality of care.

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Are women finally being heard?

Women in the UK are becoming increasingly vocal about the challenges they face in their healthcare and the unjust variation in access to services. When the Government opened their consultation to inform a Women’s Health Strategy in Spring 2021, over 110,000 respondents took the opportunity to make it known that the system does not work for them. Following years of campaigning, it comes as no surprise to women and those in the women’s health community that an overwhelming 84% of people felt their voices are simply not being heard when they seek health care.

By demonstrating an interest in women’s voices and their experiences, recognising failures in the system, and committing to developing a Women’s Health strategy, the Government has taken a positive initial step, albeit an ambitious one. There is no disease-specific focus and no target patient population, unlike other policy areas. This challenge affects 51% of our population and includes natural, life course events that women have, for many years, been told to just live with. With publication of the strategy imminent, the Government now need to demonstrate that they are willing to not only listen to women’s voices but to implement action based on what they are saying.

Women continue to face challenges when it comes to choices about their own bodies. Ongoing variation in access to abortion care, a full range of contraceptive choice, and a holistic range of menopause treatment options, all impact on women’s freedom to choose the treatments that work best for them. The Government’s commitment to prioritising the menopause in the upcoming strategy and cutting prescription costs for Hormone Replacement Therapies (HRT) in response to the Menopause Revolution campaign is hopeful. However, the Government’s initial attempt to reverse progress made in at-home abortion during the pandemic despite women citing a clear preference for this to continue, suggests more need to be done to prioritise women’s voices, choices and rights in practice.

In addition to not being heard, a fragmented system and the pandemic backlog have resulted in services that are increasingly difficult to navigate, leading to the most vulnerable falling through the cracks. Upcoming system reforms focusing on the integration of care offer opportunities to take a patient centered approach and reduce inequalities in outcomes. The Government is also expected to advocate for the establishment of ‘women’s health hubs’, which aim to enable access to all required care in a one-stop shop, in line with calls from advocates including the Primary Care Women’s Health Forum and Royal College of Obstetricians and Gynaecologists. Despite the promise of better integration locally, fragmentation is continuing at a national level. Abortion has been removed from the Women’s Health Strategy and is expected to feature in the upcoming Sexual Health Strategy. With a wider interest in health inequalities, the Government must recognise the connection between these elements of healthcare and align planning nationally to support local areas to integrate care.

Committing to a women’s health strategy is a promising step in the right direction for this Government and has offered women long overdue hope. Action in response to prominent campaigns, such as the Menopause Revolution, to change the way women can interact with the system allow us to believe that the challenges women have faced for far too long could be overcome within their lifetime.

The Government have a real opportunity to ensure women have their voices heard. To do this, they must recognise the challenges they face, capitalise on system reforms to integrate care, collaborate with the women’s health community, and most importantly, commit to funding appropriate and immediate action. In a health system and economy designed by and for men, the time for meaningful, impactful change, is now.

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Battle stations: reflections on the Government’s War on Cancer announcement

When the Conservatives were re-elected in 2019, it was on a manifesto that mentioned cancer in only two specific commitments: the expansion of the Cancer Drugs Fund and the rollout of cancer diagnostic machines across 78 hospital trusts. And yet, at the beginning of February, the Government used World Cancer Day to declare war on cancer, announcing a sweeping consultation for a new 10 Year Cancer Plan for England, designed to “radically improve” outcomes for cancer patients.

There is no doubt that the COVID-19 pandemic has had a significant impact on cancer diagnosis and care, so, despite the surprise nature of the announcement, it’s hard to oppose the Government’s decision to intervene. What isn’t clear yet is the extent to which this will be a wholesale reform backed by serious funding commitments, or a rehash of existing policies in the 2019 NHS Long Term Plan and the 2015 Cancer Strategy for England.

The announcement shows the Government’s intention of taking the reins on cancer policy, and making it political. Following months of political unrest and serious concerns about the elective care backlog, this allows the Government to set its long-term intentions. By making cancer a political priority, the Government and NHS can be held to account on the impact of reform, ensuring delivery against commitments. This is likely to be central to the purpose of the Cancer Plan and will help to give momentum to a programme of change.

It is essential that funding is adequate to achieve targets at an extremely challenging time. Patient groups, who have witnessed years of rhetoric yet insufficient progress, are cautiously optimistic, rightly concerned that years of underinvestment and understaffing will mean that however great the commitments are, the resource to achieve them will not match.

We have also witnessed this week The Treasury being more muscular on making stipulations attached to funding commitments. The tense stand-off with Department of Health and Social Care (DHSC) over the Elective Recovery Plan may indicate what’s to come with the Cancer Plan, with the Treasury not keen to loosen the purse strings for wooly ambitions.

Whether the Plan, when published, is a total reset or momentum for existing policy in a new format, the potential for real change in the diagnosis, management and treatment of cancers is certainly closer.

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NHS outsourcing to the independent sector: politicians vs the public

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What can we learn from the proposed NHS Standard Contract for 2021/22?

What can we learn from the proposed NHS Standard Contract for 2021/22?

NHS England has published a consultation on its proposed changes to the NHS Standard Contract for the financial year ahead. The final document will be used by Clinical Commissioning Groups and NHS England to contract for all healthcare services bar primary care. The focus of any changes often provides important insight into system priorities for the coming year and the strength of conviction behind them.

With 2021/22 set to be another uniquely testing year for the NHS, one might expect measures to mitigate the impact of COVID-19 to dominate the contract. Instead, there is a sense of defiant ambition, with clear signals for providers to push on with other key NHS and government priorities.

With this year’s consultation now live, here are four key takeaways for the year ahead:

 

1. Don’t get left behind as the NHS pushes on with system transformation

The Contract for 2021/22 shows that NHS England is not letting up in its push for system transformation. It includes several steps to establish more collaborative relationships between commissioners and providers, the most symbolic of which is the removal of financial sanctions for providers that fail to achieve national standards.

This is a significant step towards reversing the transactional, almost adversarial relationship that has proliferated between commissioners and providers over recent years, instead encouraging more collaborative system-level action to identify and address the causes of poor provider performance.

The cogs of system transformation are well and truly turning again so engagement with NHS leaders will need to focus on how to support the achievement of their newly framed outcomes in the most direct way. Additionally, the prospect of major health legislation is looming large for the first time in almost a decade, providing an important opportunity to think bigger picture.

 

2. Get serious about delivering ‘Net Zero’

In October, NHS England published its report on Delivering a ‘Net Zero’ National Health Service, which set out the interventions required to achieve just that, ‘Net Zero’. Yet, the report itself had no legal standing on which to enforce its recommendations or incentivise action.

The inclusion of stronger targets on the reduction of harmful greenhouses gases and air pollution in the proposed Standard Contract for 2021/22, and a requirement for providers to identify board-level officers accountable for delivering ‘Net Zero’ commitments, is a clear indication that NHS England is serious about driving this agenda forwards.

The NHS will increasingly expect everyone who works alongside it to demonstrate that they are also serious about reducing their environmental impact. Medicines, medical devices, services and care pathways can all be made more sustainable. Clearly communicating what you are doing in this space could start to deliver a commercial advantage as pressure builds on providers and health systems to make rapid progress.

 

3. Offer a helping hand on health inequalities

Commitments to reducing health inequalities have been somewhat of a stalwart in NHS policy over recent years. The delivery of coordinated programmes at a local level that actually move the needle have not been so common. This was brought into stark relief by the disproportionate impact of COVID-19 on people of Black, Asian and Minority Ethnic backgrounds.

To create greater accountability at a local level, it is proposed that the Contract include a requirement for each provider to identify a board-level executive responsible for overseeing their actions to address and reduce health inequalities. With broader government and public focus on health inequalities brought on by COVID-19, the pressure on these individuals to demonstrate progress will be palpable.

Those working alongside the NHS should place increasing focus on how they support providers and health systems to address health inequalities. At a time when resources are stretched, we may find that some are actually more open to industry support in delivering staff training programmes, new capacity or improvements to patient pathways, but they’ll have to be able to justify the time investment. Demonstrating how you can contribute to reducing health inequalities could help to secure support for your joint working projects.

 

4. Communicate the benefits of remote consultations and management

Following the rapid up take of video and telephone outpatient appointments during COVID-19, the NHS is now trying to cement their use into everyday clinical practice by requiring all providers to offer patients (where appropriate) a choice between remote and face-to-face consultations. The hope is that this choice will be maintained in primary care too, where uptake of remote consultations has also rocketed.

However, to truly support clinicians and patients to select remote consultations in the long-term, the NHS will need to place additional value on health technologies that support effective remote monitoring and management.

Before some slip back into old habits, the wider health sector can play a role in crystallising broad clinical support for this new way of working. Arming your field force and spokespeople with clear, real-world evidence of how your technology is reducing the need for labour intensive, face-to-face clinical interventions could provide clinicians with the confidence to continue their transformation.

 

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A viral epidemic is becoming a mental health epidemic, but does the Long Term Plan need a rethink to cope?

Just 18 months on from the launch of the NHS Long Term Plan, is it already outdated when it comes to mental health?

As the focus of health policymakers moves from coping with COVID-19 to catching-up care across all conditions, attention is increasingly turning to the mental health catastrophe we face.

The challenge is not only stark for people living with mental ill health. It also threatens the carefully-laid strategy put in place before the pandemic struck.

Improving mental health care was at the heart of the Plan, with a promise to “deliver the fastest expansion in mental health services in the NHS’s history”. The ambition to finally establish parity with physical health was supported by significant funding across acute and community support.

But COVID has moved the goalposts and cut the game time. For this reason, the NHS can’t simply pick up where it left off with the mental health aims in the Plan. Somehow now it must go much further, and faster.

The impact of COVID-19 on mental health

It is clear that the pandemic is both a cause and compounder of mental illness.

Broadly speaking there are now two groups of patients with considerable and potentially long-term needs:

Firstly, those who already had and were undergoing treatment for an existing mental illness. COVID-19 lockdown restrictions have made access to primary services, support and therapies more challenging. It is likely that this has led to relapses and more acute mental health needs.

A recent survey by Rethink Mental Illness found 80% of people living with mental illness say the crisis has made their mental health worse. Almost half surveyed have struggled to access services.

Secondly, there is a wave of new patients who have developed mental illness as a result of COVID-19 and the lockdown. Triggers are wide-ranging, including stress regarding job insecurity, grief, isolation and anxiety over the future. There are also particular concerns over the long term impact on young people.

Each group will have different needs, with a complex mix of therapies, treatments and support. But the modelling of mental health services within the Long Term Plan was not designed to cope with a spike in acute cases or for a whole wave of new ones.

Further, as the implementation of the Plan was still in its infancy when COVID struck, much of the work will have been disrupted or delayed at the least.

What does the response look like?

This emerging backlog and new wave of patients requiring care will exert a pressure on services that hasn’t been experienced before. The NHS therefore needs to rapidly reassess how to respond to the challenge.

For example, the Long Term Plan aimed to expand mental health support services for an extra 345,000 children and young people aged 0-25, including through schools and colleges. Following months of school closures and the risks faced by vulnerable children, that number will now need to be much higher and rolled out with greater urgency. This is an additional and complex challenge for headteachers facing already unprecedented difficulties as schools look to reopen.

The ambition to expand community and hospital services, including talking therapies and mental health liaison teams is also a core part of the Long Term Plan’s aims. This has been seen as a long-overdue measure to provide the appropriate level of care for hundreds of thousands more people with common or severe mental illnesses. But policymakers and the health service will have to consider what a best ‘new normal’ and staffing levels looks like to ensure services can provide the levels needed.

There are glimpses of positives. NHS England has brought forward implementation of a 24/7 crisis helpline and announced extra funding for the mental health charities at the frontline of dealing with the COVID fallout during Mental Health Awareness Week.

Yet the money attached to mental health in the LTP is now superseded by the new situation. Undoubtedly more will be needed.

A new generation of political leadership

While not all will agree with Luciana Berger or Norman Lamb’s politics, Parliament lost two of its biggest mental health champions in December. New parliamentary mental health champions are stepping forward and they have an important job to play.

Promisingly, beyond COVID, mental health is the key health issue for parliamentarians. WA’s January survey of the new parliament’s health priorities saw mental health care emerge as MPs’ top priority for additional NHS funding, with two thirds choosing it as an option. But despite growing awareness of the looming mental health crisis, there has been little political focus on what needs to happen next.

It is essential that the progress made over the past few years in mental health doesn’t fall to the wayside because of COVID. A rapid review of the Long Term Plan – with a COVID lens – backed up by sufficient funding and implementation, is needed to stop the viral health epidemic becoming a mental health epidemic.

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After COVID-19, what next for cancer services?

Thousands of cancer patients are missing. Many patients are having appointments delayed or cancelled, others simply aren’t seeking help. There is growing unease over the implications.

And so the direction from the centre is clear – getting cancer services back up to pre-pandemic levels is a top priority for the health service.

How this will be achieved remains to be seen, with many remaining unknowns around how, when and which services and standards will be brought back.

As the health system starts to piece together a path towards the new normal, we provide a recap of the key decisions made during the pandemic and some of the remaining questions that will be playing on the minds of those tasked with delivering the cancer recovery.

A pause on the 28-day faster diagnosis standard (FDS)

Due to be rolled out fully from April 1st, NHS England and Improvement cancer leads confirmed that implementation of the FDS would be put on hold indefinitely. While providers have been asked to continue sending data, they will not be expected to meet the 75% threshold and no data will be published until at least July.

Cancer providers will be anxious for further guidance over expectations when the NHS formally enters the “recovery” phase. With the need to maintain surge capacity alongside an anticipated backlog of pent-up demand for cancer services, there will be tough decisions to be made over how much leeway can be allowed for services that will undoubtedly continue to be stretched thin over the foreseeable future.

Maintaining impetus on early cancer diagnosis in primary care

The re-worked primary care network (PCN) contract for 2020/21 pushed back the start date for the Early Cancer Diagnosis service specification from 1 April to 1 October, while urging PCNs to “make every possible effort” to begin work earlier if possible.

This plaintive request from the centre was no doubt made against concern over the impact of the suspension of all cancer screening programmes. Together with screening, the service specification is integral for achieving the Long-Term Plan ambition to diagnose most cancers at an early stage.

It includes considerable administrative asks of PCNs, including a rigorous review of their referral practice and targeted action to improve the uptake of cancer screening services. Whether this can feasibly be done amidst the current situation remains to be seen. With no further signals on the resumption of the cancer screening programmes, much depends on PCNs’ ability to drive progress on this front.

Accelerating the roll-out of Rapid Diagnostic Centres (RDCs)

Many RDCs across the country have continued to operate during the pandemic, and NHS England has recognised their potential to support the COVID-19 response with guaranteed funding flows as required. The pandemic has accelerated the introductions of innovative approaches to manage referrals to RDCs and avoid hospital attendances, which may well continue well beyond the current crisis. At the same time however the submission of RDC management information has been paused, as has the planned national RDC evaluation exercise.

As services begin the task of bringing referral and diagnostic activity back to pre-pandemic levels, the expectations of RDCs will be high – the challenge will be to ensure that their learnings and good practice can be shared effectively across the system.

Continuing uncertainty over shielding

Little has been said officially over whether individuals who have been advised to shield during the pandemic, many of whom are cancer patients, will be asked to continue isolating in the coming weeks and months. Reports of recent communication by text message with those on the shielding list has indicated that some individuals are being removed from the list, although nothing has been announced on the rationale behind this decision or which groups will be affected.

Cancer Alliances have reported significant falls in 2WW referrals for suspected cancer, with anecdotal reports of some patients refusing to attend for fear of infection. Any continued ambiguity in the official advice will only exacerbate the concerns of vulnerable patients and will need careful management in order to ensure that cancer patients are receiving appropriate treatment and support.

Responding to the pandemic required rapid changes to cancer services and the necessary suspension of initiatives that were just gathering momentum before the crisis hit. What’s clear is that the task of piecing cancer services back up to pre-pandemic levels is just as complex, and there is a lot of remaining uncertainty as to where and how priorities should lie.

 

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What does no deal risk losing in the NHS Long Term Plan?

In launching the NHS Long Term Plan, Theresa May promised stability amidst all the instability. Key headlines include half a million lives over the next ten years to be saved through preventing diseases such as strokes and heart disease, and true efforts to bring parity to mental and physical health.

But with fears increasing that Theresa May is ‘thinking the unthinkable’ and seriously considering a no-deal Brexit, key policies within the Plan could be at risk before they’ve even begun. Here, we focus on four areas underpinning the Plan that are at risk from a no-deal Brexit:

  1. The money behind the Plan

Before the Plan came the financial commitment: £20.5 billion more for the NHS over the next five years.

But as Bank of England Chair Mark Carney said last week, “A no-deal would be an economic shock for this country.” The UK economy expanded in 2018 at its slowest annual rate in six years, and a no-deal Brexit could continue, or even worsen this. Under World Trade Organisation Tariffs, the UK could have more expensive imports, less demand for exports and potentially cause a greater reticence from the government to borrow at what will inevitably be higher rates.

Simply put, no-deal is likely to give the Treasury less spending power and flexibility.

Due to a fortunately timed windfall from higher than expected tax income, the Plan’s funding is supposed to be guaranteed. But any major hit to Treasury revenue could mean that the designated budget must be drawn from elsewhere. It will have to be raised through increased taxation, borrowed, or moved from other departmental budgets – highly contentious when other public services will inevitably have to undergo (further) cuts.

  1. Relieving pressure on hospitals by increasing care in community settings

A major pillar of the Plan is for more patients to receive care in primary and community settings, rather than in hospitals. This has been a longstanding ambition of this and previous governments but has been notoriously hard to deliver.

An extra £4.5 billion a year has been ringfenced for the increase in primary care capacity and shift to a more integrated approach. But reducing hospital care also relies on effective and complementary social care services, the often-ignored, yet critical part of the puzzle. As Simon Stevens has reiterated many times, a failure to deliver on social care will lead to a failure to achieve on the Long Term Plan.

Yet the long-awaited social care green paper has been delayed because of Brexit. Current thought is that it will land in April. But a no-deal will inevitably change the scope once again or even delay the Green Paper indefinitely.

Ideas rumoured to be considered for inclusion, such as tax incentives for young people to save for their social care, will have to be reconsidered against what will be politically palatable and financially necessary following a hard Brexit. With this further delay, the risks grow that social care reform will once again be kicked down the road.

  1. Increasing the NHS workforce

There has already been plenty of criticism at the Plan’s lack of focus on workforce, which is understandably seen as a critical tenet of its successful delivery.

The BMA has repeatedly highlighted the risks of the high level of vacancies in the NHS’s workforce. Ruth May, NHS England’s new Chief Nursing Officer, reiterated the point in her first interview. For a sector already struggling to cope, a no-deal exit would make this challenge even more acute.

At almost 70,000 individuals, the current number of EU nationals working in the NHS is staggering. Any reduction in this number would hit services hard, and undoubtedly reduce the ability to deliver appropriate, and necessary levels of care.

Under pressure from NHS leaders, a workaround has been agreed. In the event of a no-deal, EU citizens coming to the UK will be permitted ‘temporary leave to remain’, giving them the same rights they have now.

But note the ‘temporary’ aspect, which is crucial. It grants permission to stay for just three years and with no extension ability. Applying for Indefinite Leave to Remain or a Tier 2 Visa are the only other routes, undoubtedly acting as a deterrent to many.

Even if a deal is agreed, the workforce questions are likely to remain. All eyes are on the Workforce Implementation Plan proposals, expected in early April, and the eventual full Plan within two months of the Comprehensive Spending Review.

  1. Improving outcomes for all major conditions

While improving outcomes for major conditions relies on multiple, complex factors, a key factor is to ensure patients receive the right care at the right time.

This necessitates uninterrupted access to treatments and therapies. The Department of Health and Social Care (DHSC) and NHS England have been keen to reassure the public that there will be no interruption to medical supply, no matter the exit scenario. Huge sums have been spent testing scenarios and creating contingencies by industry and government to ensure continued access to medicines. But questions remain over the ability to maintain supplies in a volatile, hard Brexit scenario.

Diabetes UK and JDRF last week published a joint statement calling on the Government to provide more detail on access to insulin in the event of a no-deal. And today, HSJ has a splash from the Royal College of Radiotherapists, saying that if a no-deal Brexit delays the import of radioisotopes NHS trusts will have to prioritise which patients receive cancer treatment, meaning some cancer treatments may be delayed.

While the necessary customs forms and transport arrangements will undoubtedly be prioritised and agreed relatively swiftly, this is unchartered territory and a no-deal Brexit will test the preparedness to the limit. The potential impact on patients in the meantime is highly concerning.

The Long Term Plan has been one of the few glimmers of domestic policy success for Theresa May’s battered government. While considered challenging to deliver, there is optimism in and across the health sector that progress can be made. However, there are growing concerns that a no-deal Brexit risks destabilising many of the Plan’s core ambitions, potentially undermining it from the offset. Providing stability amongst the instability may not be straightforward after all.

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Winners and losers from the NHS Long-Term Plan

The launch of the NHS Long-Term Plan is intended to set the direction for NHS policymaking for the next 10 years. The 134-page report signals a shift in priorities and an evolution of focus. As always, this means winners and losers.

As the dust begins to settle on yesterday’s plan, we take an early look at the beneficiaries of this plan, and areas left out in the cold.

Winners:

Primary and community care networks – the new poster child of the NHS?

In line with Matt Hancock’s own priorities, prevention was the buzzword in advance of the official launch, and the expanded role of community care was borne out in the detail. One of the centrepieces of the plan is the roll out of primary care networks (an evolution of the GP Federations) backed by £4.5bn of funding by 2023/24 to deliver meaningful integration at the community-level. Out-of-hospital care is once again the name of the game for NHS planners – although this longstanding ambition is notoriously hard to deliver on the ground.

Mental health services – big on ambition, but challenges remain

As heavily trailed, mental health services for both adults and children figure significantly in the NHS Long Term Plan. Parity of esteem may finally be turning from words into action. Well known to be one of Theresa May’s pet policy areas, a number of eye-catching initiatives – such as mental health ambulances and services for 0-25 year olds – make it into the plan, alongside the renewed commitment for faster growth in mental health services funding against the overall NHS budget. However, realising the ambitions the plan sets out for the sector is unlikely to be plain sailing, given funding earmarked for mental health has failed to reach the frontline in the past and deep-rooted workforce and capacity issues remain.

Theresa May – an NHS plan a day keeps Brexit away

Yesterday’s announcement was – for once – a relative success for the Prime Minister. Having had to postpone publication from 2018, this was May’s opportunity to set the news agenda with important and ambitious domestic policy. Rather than another day solely dominated by a Brexit back-and-forth, she was able to come out with a proactive and positive message which, on the whole, has gone down pretty well.

Digitised GP consultations – the gardens of Babylon

Under the Long-Term Plan, digital-first primary care will become a new option for every patient within five years, drastically increasing the availability and uptake of services such as GP-at-hand. Good news for providers, but these services are not without controversy, and this move will not go unnoticed by the small army of clinicians on Twitter who describe them as untested and unsafe. As a vocal proponent of the digital approach, the inclusion of this measure is a win for the Health Secretary.

Global health recruiters – looking further afield for NHS talent

The workforce implementation plan, due to be published later this year, will have a major focus on recruiting NHS staff from overseas. An expansion of the Medical Training Initiative to ensure clinical trainees from around the world can learn in the NHS is being considered, while the government’s Immigration White Paper also gives the NHS more opportunities to bring in new talent from outside of the EU. However, the gaps are significant and growing, and there remain major question marks around the nursing and social care workforce when it comes to international recruitment.

Losers:

NHS managers – what’s another strategy among friends?

Nigel Edwards, CEO of the Nuffield Trust, reiterated his concerns about the capacity for rolling out such wide-ranging changes in an already stretched and reorganisation-fatigued organisation. For NHS managers, the Long-Term Plan represents yet another document to be implemented, in some cases with additional checklists and bureaucracy, at a time when the integrated care systems programme was just beginning to bed in. A new set of responsibilities and targets, alongside new uncertainty over the statutory role of CCGs, does little to ease the headaches of front-line planners and commissioners.

Local authority funding – the elephant in the room

Few in local government would have been under any illusion that the NHS plan would equate to a spending bonanza on social care and public health, but for all its warm words, the document gave scant comfort. Decisions over social care and public health funding have been deferred until the spending review expected in the spring, while services are desperately struggling to cope with demand. For a plan so focused on prevention, commentators have been quick to point out that local authority public health budgets continue to be cut. Floating a possible solution of reabsorbing some public health services – such as sexual health – back into the NHS is likely to irritate rather than comfort.

The life sciences sector – limited language on innovation in treatment

The Long-Term Plan launched with two clear messages – that decreasing demand is the aim and that prevention is better than cure. Primary prevention and earlier diagnosis has taken precedent over world-class treatment, with medicines featuring sparingly in the document. Pharma is well aware that the battles on pricing and access will take place elsewhere, but for industry already feeling under pressure in the UK market, mentions of the role of innovative treatment would not have gone amiss. Still, there are green shoots for anyone involved in genomics, and nods to the growing importance of precision medicines.

2012 Health and Social Care Act – another nail in the coffin?

The NHS plan represents another step towards unpicking the Health and Social Care Act. As requested, Simon Stevens (in consultation of course) spells out exactly which parts he would most like to remove through primary legislation, should the opportunity become available. The plan describes primary legislation as having the potential to ‘rapidly accelerate’ the progress on service integration as well as cut out counter-productive and bureaucratic competition and compulsory tendering processes. In truth, a Brexit dominated 2019 makes it very unlikely that MPs will have the chance to get their teeth into a health bill, so the existing fudge will have to do.

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