On track?

From the uncertainty created by the general election to the furore over the GP contract and the reality of integrating budgets, the past 15 months have posed some major challenges for the NHS Long Term Plan.

Yet these issues could be the tip of the iceberg if England faces a coronavirus epidemic as this could seriously disrupt NHS services over the next few months.
In this article, we explore some of the key barriers to the roll-out of the NHS Long Term Plan and how they are being tackled. We also assess what is likely to happen next and what this means for pharma.
Integrated Care Systems (ICSs)
Moving from a ‘shadow’ ICS to a fully fledged one is proving challenging, particularly with regard to finance. NHS England and NHS Improvement expect an ICS to have accepted a single control target for its health economy. However, to date, only Dorset ICS has used all of its sustainability funding to meet the collective control total.
All other systems, even those that have been accepted as a fully fledged ICS, such as Surrey Heartlands and Bedfordshire, Luton and Milton Keynes, have resisted pooling all their sustainability funding – keeping much of it linked only to individual providers’ financial targets.
This underlines the difficulty of getting different people in different organisations, with different pressures and legal obligations, to share and take risks together.
To help tackle such problems, the government has promised to legislate to enshrine the Long Term Plan in law and remove competition law. We may also see ICSs become statutory bodies like NHS Trusts and CCGs. All of this would help to smooth the path to integrated working.

Other key integrated care bodies
Integrated Care Providers (ICPs), which were designed to contract with strategic commissioners, are still at an embryonic stage and do not have any contracts in place. A new ICP contract is expected to be awarded in Dudley later this year. It will be the first ICP contract in England and is forecast to be worth up to £360 million annually.
Primary Care Networks (PCNs), which were launched last July as an extension to the GP contract, are key to delivering the Long Term Plan. However, they ran into trouble recently when the British Medical Association’s England GP committee condemned the draft service specifications outlining what is expected of PCNs over the next four years.
Fortunately, GPs have since agreed a new deal with NHS England following a consensual process. This will see two planned new services, anticipatory care and personalised care, dropped from the 2020/21 contract and more money overall for PCNs.

Local plans
ICSs and STPs were tasked with creating their own local versions of the Long Term Plan by mid-November 2019, but the deadline was delayed because of the general election purdah period. Although these plans have been written, they still have not been published.
So, what has happened to this key plank of the Long Term Plan’s strategy? It appears that local plans have been subsumed into the commissioning intentions of Clinical Commissioning Groups (CCGs), which suggests that CCGs are still holding the reins in terms of prioritisation and budgeting at a local level.
Another key point is that although these plans were collaborative at a senior level within ICSs and had programme managers working in key areas, such as cancer, diabetes, respiratory conditions and cardiovascular disease, providers have not had much involvement. Few clinicians will know details of the plans hence there is an opportunity for pharma companies to support clinicians in this regard.

Knowledge is power
The new and emerging integrated care organisations will all be key customer groups for pharma, so it will be vital for industry to keep abreast of the latest developments, including the local health system plans which will contain local disease strategies.
Board meeting minutes are a particularly good source of information. Sophisticated tools, such as Wilmington Healthcare’s Investigator, enable pharma to search these documents as well as the latest guidelines, pathways and local NHS priorities.
Armed with this level of data and insight, pharma can begin to determine how to dovetail its drugs and services with wider NHS priorities outlined in the Long Term Plan, such as changing outpatient follow-up appointments to digital options and moving more care into the community.
For example, in dermatology most care is delivered in an outpatient setting, so any changes around planned care and outpatient services would impact on that therapy area. Since these departments have to manage large numbers of patients with concerns about skin cancer, the ability to provide care elsewhere for patients with chronic skin conditions could prove invaluable.
Empowering PCNs to provide end-to-end care for people with severe eczema or psoriasis, for example, rather than referring them all to hospital dermatology departments is one potential option. Enablers for this change could include drugs that do not require monitoring, or ones that can be administered in primary care by a multidisciplinary team member or even by the patients themselves.
These benefits could also be shown to help to reduce pressure on the NHS workforce and enable healthcare professionals to work smarter. This is key given that a lot of change in the Plan is designed to be clinically led and relies on staff on the frontline forming multi-disciplinary teams in primary care. However, the NHS is struggling to recruit new nurses and clinical pharmacists and retain GPs.

Central control
Local stakeholders working together to create a system that is fit for purpose in a particular locality, without any interference from government, is a key principle of the Long Term Plan. But as can be seen from the experience of the ICSs, for example, it can be fraught with difficulty and in light of the challenges there could be a rethink about how to make ICSs work.
Indeed, it is possible that the NHS may turn full circle and decide that to make large-scale change happen it has to be driven from the top down, to some extent. The recent appointment of former health secretary Jeremy Hunt as Chair of the Health and Social Care Select Committee could be a sign that the government is changing its approach.
The prominence given to current health secretary Matt Hancock and his digital initiatives also suggests that the government is tightening its grip on the NHS as it comes under pressure to deliver its general election promises. We could see change foisted upon local systems with regards to switching to digital services or making primary care and community care take on more responsibilities.

Coronavirus
With widespread transmission of the coronavirus in the UK now “highly likely”, according to Public Health England (PHE), the Plan could face its biggest challenge so far if there is an epidemic in the country.
England’s Chief Medical Officer, Professor Chris Whitty, has warned that the NHS might have to be reconfigured “quite profoundly” during the virus peak if cases reach high numbers. As well as postponing elective procedures, other “more radical measures” might be required. Options such as video consultations may be widely used.
There is a sense that some goals the Long Term Plan aims to achieve, such as freeing up hospital beds, might not happen because all those beds will be filled by coronavirus patients. Yet, unwittingly, perhaps the coronavirus might turn out to be a real-life test of some of the transformational activities that the NHS has been hoping to achieve.
Conclusion
As we move into the second quarter of 2020, there is a huge amount of uncertainty – not just around the practicalities of delivering key tenets of the Plan, such as integrated care, but also the threat of major disruption from the coronavirus.
While the plan is ‘long term’, and integrated care isn’t due to be in place across the whole of England until April 2021, the clock is ticking, and the NHS has to make some radical changes to achieve its goals.
Given the challenges to date, it is likely that the government, which promised to put the NHS at the top of its agenda, will begin to enforce more of a ‘top-down’ approach to deliver the integrated future it has promised.

As ever, it will be vital for pharma to closely follow these developments, map the key stakeholders in new and emerging integrated care organisations and keep abreast of local plans. Armed with the latest data and insight, industry will be best placed to support its customers through the changes and challenges that lie ahead.

‘The new and emerging integrated care organisations will all be key customer groups for pharma, so it will be vital for industry to keep abreast of the latest developments’