Crystal clear?

Looking Ahead: How to engage with the NHS in 2023

Make no mistake, you don’t need precognitive powers to forecast this year’s set of challenges.

Suboptimal care (for patients), financial constraint and operational hurdles (for NHS leaders), unprecedented workload and competition for increasingly scarce resources (for clinicians), and a scrabble for access, adoption and increasing market share (for pharma – and that’s before we even mention the VPAS increase).

Wilmington Healthcare’s stablemate Health Service Journal has explored this via its excellent HealthCheck podcast – What does 2023 have in store for the NHS?

The HSJ team’s main warning is a financial one. System deficits will return, as the extra money the government announced in autumn to cover inflation gets swallowed up by year end. There also won’t be enough to offer staff an acceptable pay rise; there will be more strikes; and patient care, the backlog and overall standards of access will continue to slip.

Furthermore, the NHS will be under intense political pressure to ‘change’ as these waits and restrictions continue. HSJ’s Editor Alastair McClellan’s leader ‘The Year of the Great Distraction’ eloquently put it thus: ‘faced with a crumbling service there will be inexorable pressure for ‘something to be done’.

That ‘something’ will not be anything meaningful, so we will all have to endure the ‘great distraction’ of a parade of proposals ranging from the blindingly obvious (and already being undertaken) to the long discredited.’

The number one problem for the NHS remains workforce, and until a government steps in to fix this, it wont matter how many beds are freed up, as there won’t be enough staff to tend to them. And as stress and poor working conditions mount, the list of vacancies will rise even higher than its current 133,000, worsening this problem.

So, what can industry do to improve its situation during this all-pervasive and seemingly interminable omnicrisis? Below I give five areas to understand this calendar year – to help you prioritise, refine your strategy and make some progress with your NHS customer.

Help the NHS recover

The key publication in understanding NHS priorities for 23/24 is the NHSE Planning Guidance.

This document spells out three priorities: recovery, execute the long-term plan and transforming services. Take note that the first driver is recovery, and this will continue to be the case, until the NHS is off the front-page news.

While GP appointment delays and elective surgery backlogs provide constant background noise, the most glaring area of public disenchantment is A&E waiting times. That’s probably why NHS England is handing Trusts a new target to see 76 per cent of accident and emergency patients within four hours by the end of 2023-24 –the first hurdle for any NHS system to make sure they clear.

And although this may not seem at first to be relevant to pharma, think of it this way: this uber-target leads to other targets that help support it – understand these, to align your approach with what the NHS is really trying to do at the moment.

A&E can only be cleared when there is more capacity. More capacity can only be achieved when dischargeable patients start leaving, and fewer long-term condition (LTC) patients need emergency care.

For example, already in the CQUIN (the Commissioning for Quality and Innovation incentive payment scheme) published concurrently to the Planning guidance, we see targets that urge the use of medicines to support early discharge, and a switch from IV to oral as soon as possible to enable patient care in non-hospital settings.

The NHS simply must shift patients out of acute care beds, or prevent them arriving in the first place. If you have any angle on this via your product, service or preferred pathway, this is something you can leverage.

When putting together a value proposition, remember to take into account this overall need, and emphasise the capacity of your drug to support self-management, or management outside hospital – and decrease the likelihood of an LTC deteriorating.

Activity is key

Embedded in the planning guidance is a reboot of payment by results for 23/24, the activity-based payment system where providers are given more funding based on how many procedures are carried out.

PBR was criticised for not incentivising quality or outcomes; and it was scrapped just prior to the pandemic in favour of a more blended payment system that included outcomes-based payments and variable payments for achieving locally negotiated markers.

Now, with the backlog in elective care, it’s back, and this will mean companies have to get to grips with a new understanding of healthcare costs within a service, and within a system, and try to understand how their medicines fit in to the overall spend.

That said, it’s important to remember that a lot of NHS cash will still remain in some form of block contract, so look at the overall funding picture of a service – this will help you discern where your intervention can create efficiencies.

And note that PBR won’t include follow ups – these are excluded as the NHS moves to PIFU – patient-initiated follow-up.

Becoming a local hero

In the new NHS, systems vary widely from each other in terms of maturity and sophistication, how well integrated they are, how financially constrained, how adaptive to innovation and how well they get on with industry.

This trend looks set to continue with Chancellor Jeremy Hunt calling for fewer top-down targets and more locally driven initiatives, which will mean that different areas have different priorities, different delivery mechanisms and different overall aims.

One thing you can do is follow the local five-year plans that each integrated care partnership must now submit by March 2023. Co-authored by the ICB and providers, these will give you a good indication of how each area is going to set about achieving the recovery, long-term plan, transformation triangle.

It’ll give a good idea of disease area priorities, service redesign and pathway development going on in an area you’re interested in.

Another key document is the Hewitt Review, led by the former Labour Health Secretary Patricia Hewitt, which focuses on how to make integration work to improve outcomes for patients.

The review’s terms seem to favour ‘earned autonomy’, in which greater local NHS freedom from central control is matched by delivering progress on priority areas and demonstrating local leadership capability.

This kind of localised sales and marketing, where messages and engagement are differentiated according to local need, will help pharma get noticed at ICS level.  Supported by a good knowledge of local clinical realities (for example, via use of clinical audits in your therapy area), it’s an excellent strategy for your 2023 NHS approach.

It obviously requires a rethink in how stakeholders are mapped; in each locality there will be system leads, programme leads, clinical managers and ICS pharmacists that will need uncovering and engaging.

This will require accurate, granular and smart data, based on knowing who is most likely to affect service change, pathway change and prescribing change – and which areas are worth pursuing in the first place.

Don’t get caught out

I’ve had several conversations recently with pharma managers who were not aware that the specialised commissioning budget (which pays for many high-cost drugs) was being delegated to local ICSs (originally slated for April 2023, now moved forward to April 2024 as too few systems were ready to take it on).

It’s crucial to keep an eye on this this year. Once effected it will mean ICS stakeholders (with local priorities) will hold the budgets for many more HCDs. Although the decision-making unit will likely include a more regional-wide group (for example, around the size of a cancer alliance territory for cancer drugs), it does represent a step change from how drug funding has been done for the past ten years.

Pharma must understand each ICS’ or group of ICSs’ approach to this; will it be at ease with a cost-and-volume approach and sign off drugs at arms’ length, or will it try to create efficiencies within its overall contractual funding envelope? How will it prioritise certain therapy areas? Who will make these decisions at local level?

Sustainability and equality

Don’t be fooled, these won’t be the first things to go in the crisis. Alongside its many other challenges NHS systems must address sustainability (and not just in terms of the NHS reaching net zero, but in the wider sense of providing services that can be sustainably rolled out in future years). What is the long-term goal of using your drug for a system?

Moving what was once an acute specialty into primary care – for example, dermatology? Allowing care by staff other than consultants? Reducing the overall disease burden? Turning a killer disease into a manageable long-term condition? All of these are plausible aims for new interventions and pathways, and you can take steps to ensure that your messaging includes this sense of sustainability.

Equity of access is even more important to bear in mind. The NHS saw during the pandemic that it was not reaching certain groups, with devastating consequences in health outcomes. These ‘missed patients’ go on to develop more serious, life-threatening conditions that consume more resources and staff time.

To diminish this cohort, patients in marginalised groups must be actively sought out. These include older patients, the disabled, digitally excluded or rural groups, certain ethnicities and those in areas of socioeconomic deprivation, many of whom are unscreened, undiagnosed or not yet on-pathway.

It’s possible to find out firstly how many of these patients are in your area, and also what the local NHS is trying to do about it. Companies may have their own data – if not, companies like Wilmington Healthcare specialise in this. If you have it, then act on it; addressing health inequalities provides a win-win for both supplier and NHS; the NHS finds the populations it needs to treat urgently for fear of deterioration; the company finds more patients to benefit from its drug.

Final analysis

This will be one of the NHS’s toughest ever years. The response from pharma will need to be empathetic, supportive, realistic and smart. Access is as difficult as it has ever been. Old models of call and contact are beginning to break down, and a focused, territory specific approach supported by intelligent resourcing, MSLs, omnichannel marketing and education, and sophisticated data tools is coming to the fore.

If you can absorb the scale of the crisis, find an angle on how your portfolio can help, and remember always that the NHS is interested in patients and pathways first, and products later, then 2023 could be a positive year for your NHS engagement.

Oli Hudson is a consultant at Wilmington Healthcare. Go to wilmingtonhealthcare.com