20-21 - Getting it right first time – pharma’s chance to shine?

Originally launched in 2015 by clinical improvement guru Professor Tim Briggs, the Getting It Right First Time (GIRFT) programme has become a leading authority for quality improvement managers in the NHS.

Last month, it published an impressive new series of reviews, covering no fewer than 18 subject areas. This latest bounty is not only an extraordinary feat of evidence gathering but also provides a powerful illustration of how mindset in the NHS is shifting.

Early GIRFT reports, reflecting their initial focus on efficiency savings, tended to focus almost exclusively on acute care, looking narrowly at what could be done within the hospital walls to optimise available resources, improve clinical outcomes and minimise the amount of time patients spent in hospital.

Yet, while getting people in and out of hospital faster remains an important concern, these reports are much wider in scope; they scan whole pathways for ‘unwarranted variations’ in practice revealing what needs to happen, not just in hospital clinics and operating theatres, but in GP surgeries and community services to improve patient outcomes.

So what should industry take from this? It is hard to do justice to such a wide-ranging series in a single article, but a snapshot of just four out of the 18 reports illustrates the potential opportunities for pharma to capitalise on the key recommendations.

Let’s start with ophthalmology, which in many ways provides a perfect example of the conundrum the NHS faces. Even before the pandemic, ageing populations meant that demand on services was forecast to soar, and problems with diagnosis and treatment can have devastating consequences, with over 20 people a month losing their vision due to delays in receiving follow-up care.

As such, it’s a specialty ripe for redesign; as the report says, there needs to be ‘a focus on rethinking the way ophthalmology services are delivered, looking at how to make the best use of all available resources, including primary care, to deliver the right care in the right place at the right time.’

Its conclusions range from improving screening and referral rates to increasing the efficiency and volume of treatments administered, as well as enhancing data, developing the workforce and making better use of primary and community ophthalmologists to support more integrated models of care.

Within this, there are some clear opportunities for pharma. These include supporting effective stratification of patients to help prioritise follow-up treatment; identifying cohorts of patients who may be ‘lost’ within a pathway due to delays in follow-up, and building specific capacity to administer wet AMD treatment for macular degeneration by training more healthcare professionals to carry out injections.

Dermatology, like ophthalmology, is another specialty coping with major capacity issues as a result of increased demand and a long-standing shortage of skilled clinicians, with over 150 consultant dermatologist posts currently vacant.
What is striking about this GIRFT report is its focus on recalibrating pathways so that more care can be delivered in primary and community settings as well as the increased appetite to work in new ways, using remote technology where appropriate to do so.

One potential avenue for pharma to explore is around workforce development programmes that can help GPs, pharmacists and physician associates to develop deeper understanding of dermatological conditions and how best to triage them safely.

A second important area of debate involves where treatment actually takes place. The report recommends a clearer delineation between day case and outpatient surgery and new funding arrangements to reflect the need for surgery to take place in the most appropriate setting. This will have potential implications in terms of footfall into different providers, something our Quantis analytics tool can help you track.

A third and final aspect for pharma to consider concerns the report’s focus on variation in uptake of biologics for conditions like psoriasis. The reasons for this include differences in how CCGs are interpreting NICE guidance and clinicians’ readiness to use newer drugs – but there is, nonetheless, an opportunity for industry to audit and address any inconsistencies in access to biologics across different localities.

The diabetes specialty report builds on these themes, focusing on the multidisciplinary workforce necessary to support patients in and out of hospital and reflecting the need to bear down on avoidable harms in and out of hospital – including insulin errors, hypoglycaemic events and preventable ulcerations and amputations caused by diabetic complications.

While a big part of the challenge is again about workforce capacity – in 2017 just a quarter of hospitals did not have a single diabetes inpatient specialist nurse, for instance – there is an important role for pharma in using data and intelligence to help NHS providers to identify and target cohorts at particular risk of avoidable harm.

There are also some notable opportunities to partner with NHS organisations on training and education programmes for staff and patients. For example, the report says that despite almost 40 per cent of patients treated in hospital experiencing an error with their insulin dosage during their stay, many Trusts have no structured programme to train staff on diabetes management; some smart strategic partnerships could surely fill that void.

Similarly, it talks about wide variations in the type and quality of patient information and education provided by the NHS, with the report recommending that a quality-controlled QISMET-accredited course becomes the ‘standard’ offering for all type 1 diabetic patients. Again, the door is open for enterprising pharmaceutical companies to provide some added value through well-targeted partnership working.

Finally, it’s worth noting that better procurement is also in the GIRFT team’s cross hairs, both in this report and elsewhere in the series. It identifies considerable variation in procurement of diabetes technology and medicines, pinpointing glucose testing strips as an example where better procurement, along with better prescribing practices, could save the NHS as much as £25 million.

Renal medicine was hit doubly hard by the pandemic, firstly in terms of the disruption and cancellations experienced by existing patients as services were reduced, and secondly because of the unprecedented numbers of people with severe COVID presenting with acute kidney injury, the long-term effects of which are still being counted.

The GIRFT report for this specialty, based on a systematic review of all 52 renal centres in England, reflects some familiar themes: namely, the importance of multidisciplinary support across the patient pathway; the need to reduce variation in access to organ transplantation and referrals onto specialist pathways, and the challenge of improving quality across a range of highly specialised areas of clinical practice.

Of particular interest to pharma is the focus on medicines management, both in specialist renal centres and wider hospital settings where the report found significant variation in the extent to which the pharmacy workforce has been trained and developed to support renal services. It also identifies shortfalls in the data held on patients with advanced chronic kidney disease but not yet on renal replacement therapy – another potential area where pharma’s data and intelligence offer could be enlightening.

Finally, the report highlights the emerging importance of Kidney Quality Improvement Partnerships as a key stakeholder for industry. These replaced the Strategic Clinical Networks previously run by NHS England, and are now becoming a key incubator of quality improvement initiatives at regional level and an important strategic player in this area.

This article touches on just four out of the 18 reports produced by GIRFT – they all deserve much more in-depth study. Yet even this cursory approach helps us to sketch out the key areas in which pharmaceutical companies can play into NHS quality improvement work.

The first is around data and analysis, where pharma can enrich the NHS’s own intelligence helping them identify and address the needs of particular cohorts of patients.

The second is supporting workforce capability, where co-designed training and development programmes for healthcare professionals can offer valuable opportunities for partnership working.

The third is pathway design, where pharma can offer new solutions for supporting diagnosis, referral, treatment and ongoing care, incorporating technology where appropriate to ensure care is delivered in the right place at the right time.

The fourth is patient education, where industry can leverage its resources and expertise to help patients adhere to treatment plans and manage their own conditions more effectively.

And finally, there is the optimisation of medicines itself, including ensuring patients have consistent access to the most effective treatments for them.

The shift from disease management to population health presided over by integrated care systems will open the door for some big conversations about the future shape of NHS services.

Pharma companies that are able to engage effectively on these terms will put themselves in a strong position – and invoking the evidence in the GIRFT series could be a very good starting point.