20-21 - NHS: Game changer…

Firstly, regarding the real position of Integrated Care Systems (ICSs) in the current NHS landscape. ICSs were the next big thing for so long that when they finally went live in 2022, I had a reasonable expectation that they would hit the ground running and would be the go-to organisation for industry to engage with for improving patient pathways.

But that hasn’t been the case. ICSs are still very much in the ‘forming’ stage. More than half of them lack ‘crucial’ population health management systems that were supposed to be intrinsic to their raison d’etre. A quarter of ICBs haven’t held a meeting with their integrated care partnership (ICP) – essentially the group of providers that will be the hands to the ICB’s head.

My HSJ colleague Dave West has also written of legal, technical and financial issues and delays with delegation – with partnerships at ‘place’ level and ‘lead providers’ set to take contracts and commissioning responsibility for running various services locally. Apparently, no commissioning budgets have changed hands.

And interestingly there was little or no ICS representation at the cancer forum. The charge in oncology is at the moment being led by cancer alliances, groups of expert clinicians in pre-existing networks that are acting as convenors and fixers on local cancer policy.

ICSs lean on them for clinical improvement and service redesign – and you can be sure that when specialised commissioning eventually does become completely delegated to the regions, the cancer alliances will have a strong influence.

Cancer Alliances exist in wider footprints than ICSs, and it’s likely that this will also be the situation for the eventual spec comm map – nine organisations are slated to run this side of operations and they will be known as multi-ICBs.

For a whole swathe of specialised commissioning, not just across cancer but respiratory, cardiovascular, pain, haematology, neuroscience, dermatology, hypertension and many other areas – some 65 service lines – these multi-ICSs will be the commissioner.

For oncology, the cancer alliances lead ICSs – so it will be with spec comm services, where each therapy area is likely to have a well-networked clinical advisory group steering the multi-ICS service development. Look out for the ‘lead provider’ in each footprint – probably the main teaching Trust with specialist staff and facilities – but also the main clinical movers, as, just as in cancer, it will be these groups industry will need to empower to foster service change.

In cancer, clinical nurse specialists (CNSs) are now at the core of managing patient lists. I’ve recently done some work with some NHS clinical leaders on muscle-invasive bladder cancer – CNSs play a key part in assessing muscle-invasive patients and triaging them appropriately for surgery, chemo or radical treatment.

They need to be kept close by industry for influencing and education purposes and are a fixture of the new stakeholder map.

Other MDT members given space at the forum included physician associates. This relatively new role covers the whole pathway, straddling both secondary and primary sectors and intended to be a touchpoint for the patient, providing continuity of care.

Once compulsory registration for physician associates comes into place, their responsibilities will broaden and will involve ordering ionising radiation and prescribing. Interested? You should be.

Much of the afternoon at the forum was dedicated to addressing health inequalities, or, providing healthcare equity in cancer. An awful lot of NHS brain space is being used on this at the moment, as the link between marginalised communities and healthcare resource has been emphatically made.

In oncology the field is particularly pronounced. There are stark discrepancies in access and outcomes on the basis of socio-economic group, race, disability and gender. The example given at the forum was, in the North, if you’re old, male and poor – you’re twice as likely to die of lung cancer.

Identifying where potential patients are does the job the NHS has limited resources to fund, but also provides pools of potential patients for pharma. Supporting better outreach and access to diagnostics achieves equity, but also gets pharma’s patients onto the pathway when the chances are medicines will have more time to work, leading to better outcomes.

Having an eye for marginalised communities – those that may not normally interact with digital media, those who may not speak English, those who physically may not be able to reach centralised services – can open up dialogue between pharma, with its data management skills and patient education and information services – and an NHS desperate to reach them.

Wilmington Healthcare has developed a new product – the Cancer Pathways Tool – that drills down into the data and answers questions around healthcare equity. What, and where, are the variations in cancer care pathways at a locality level?

If you know, you can tell which areas are being affected most by inequalities, and what extra resource, financial, clinical or otherwise, will need to be applied. What are the variations are in cancer care pathways across different patient demographics such as socio-economic deprivation or ethnicity? As some conditions disproportionately affect these groups, it’s a chance for pharma to build this into the business case and show how addressing the vulnerable can lead to system-wide benefits.

Even if oncology is not in your portfolio, it makes sense to look at this area as, in it, many developments are emerging – clinical, technological, genetic – and radical treatments; but also, the use of service redesign, new roles, large and wide-ranging multidisciplinary teams, clinical networking, outreach screening and diagnostics, addressing health inequalities – that will find their way into other therapy areas.

We’re at a time when the future of the NHS is not set, but open to constant redevelopment and reinvestigation in the post-COVID world. Clearly, there’s never been a better time to engage with the health service on the things that matter to it.