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NHS
Mr. Brown has
promised a 43% increase in health spending over the next five years. So, has
the government finally realised that they are not going to get world-class
health on the cheap? Some are calling for a root-and-branch reform of the NHS
to be able to use all this investment effectively. But I thought we had just
had that?!…The final Wanless report set out the stall for this Budget,
calling for a vast cash injection over the next two decades. This 164-page
report bursts with strategies for a Utopian NHS in twenty years time. Note that
the vision of the future NHS workforce is one in which many of the first
contacts between patients and the health service will be provided by nurses in
community settings. Nurse practitioners can thus expect their roles to continue
to expand. Major acute hospitals will focus on providing 24-hour intensive and
high-dependency care.
More information ->.
The NHS Alliance is particularly pleased
that Wanless has recommended that NSFs for specific disease areas should
include estimates of the resources needed. "Our recent survey of prescribing
costs in primary care showed that 87% of PCTs were expecting an overspend on
their prescribing budgets for last year, largely because of the costs of
prescribing associated with the NSFs and putting decisions made by NICE into
practice," said Dr. Mke Dixon, Alliance Chair.
Health Secretary Alan
Milburn told the Commons how all the new money would be spent. Delivering the
NHS Plan - next steps on investment, next steps on reform spells all this out
(More information ->). I have to say it is the usual mix
of spin and recycled promises including 40 new hospitals and 500 more primary
care one-stop centres over the next five years. More nurses, more doctors. More
hospital beds. And 'foundation' PCTs…Hospitals will be allowed to
'cross-charge' local authorities for the cost of bed-blocking but will also
face financial penalties for emergency re-admissions under the same
scheme.
Last month of course also saw the massive reorganisation of the
NHS, which came in more like a whimper than a bang. The launch of one of the
biggest structural changes in NHS history saw the death of almost 100 health
authorities and the birth of 28 strategic health authorities (StHAs) and 138
PCTs but received scant media attention. Almost any year in the last decade
could have been described as one of unprecedented change, but this year does
feel different. On April 1, there were structural changes at every level of the
service - something never tried, even during the internal market reforms.
Primary Care
One
lone PCG has held onto its status, as its counterparts across England became
PCTs last month. Witham Braintree and Halstead PCG has instead opted to move
directly to Care Trust status, which it expects to secure by October. In terms
of the Care Trusts going live last month we had just four - Northumberland
(from 4 PCGs + social services) + 3 Mental Health & Social Care Trusts -
Manchester, Bradford and Camden & Islington.
As to the new PCTs,
folk are now asking that in this time of momentous change, how much control
will they actually have when much of their expenditure seems to be being eaten
away by services or central diktats over which they have no control. PCTs are
also very immature organisations that have been hot-housed to reach this stage
in their development. Many are still embryonic and some are still not at the
starting line with many key staff yet to appoint.
Appraisal for GPs was
introduced last month. This is intended to be a 'developmental process for
individual clinicians, aimed at supporting good patient care and high standards
of clinical practice in the NHS. It is about identifying development needs, not
performance management and is an important building block in the clinical
governance culture'. The BMA has said that if PCTs do not properly fund the
system (very likely!) then GPs should pull out. The total bill for a PCT might
be @ £50K - yet one more additional cost to find and another possible
area for industry partnership.
Apart from senior managers from HAs
descending on the new PCTs like a wave of Nordic invaders, at least 10 of the
new 138 PCT Chief Executives have come from Social Services. Colin Morris,
former Director of Social Services at Darlington Borough Council is Darlington
PCT Chief Exec and Nigel Porter, previously Durham County Council's Deputy
Director of Social Services is Chief Executive of Sedgefield PCT. Implications
for companies? But some PCTs still do not have Chief Executives!
There
have been a lot more adverts in the HSJ for PCT DPHs - West Yorkshire StHA
advertised for 12 posts with some very useful details given on each PCT (see
issue of 25/4/02, p. 40) and Surrey and Sussex PCTs are looking to fill 15
posts. Further information (application packs!) on the Surrey/Sussex posts can
be downloaded from
www.wsussexhealth.org.uk/pctdph. In fact only about 20% of
the 305 new PCTs apparently have public health directors appointed. Although
the expansion of DPHs from 95 positions in HAs to more than 300 is offering
public health consultants a step up the career ladder, in the longer term, we
are likely to see non-medical DPHs becoming more common.
StHAs continue
to advertise for posts in the HSJ. But StHAs seem to be struggling to carve out
their new role, a snapshot survey of chief executives by the HSJ has shown. A
month since their launch, the urgent pressures of the service and financial
framework (SaFF) round seem to have forced StHAs to revert to old 'command and
control' behaviours……But the role of StHAs in delivering the results
promised on the back of the huge rise in health spending should not be
underestimated. Although, in theory, it will be the PCTs that control the
money, their freedom to determine priorities - and therefore spending levels -
is likely to be tightly controlled by centrally determined targets, as
previously mentioned. So do get hold of their 'franchise plans' for 2002-05
(really business plans!). I note that in North West London StHA's plan, there
is provision for a pharmaceutical adviser!
Prescribing & Medicines
Management
The consultation on supplementary (dependent)
prescribing by nurses and pharmacists is now out. An important thing to note
here is that there is essentially no formulary in supplementary prescribing and
that the key will be the Clinical Management Plan agreed with the independent
prescriber.
More information ->.
The National Prescribing
Centre (NPC), in collaboration with the National Primary Care Research and
Development Centre (NPCRDC), has produced a practical guide aimed at supporting
the NHS locally in the development of effective medicines management services.
Modernising Medicines Management: A guide to achieving benefits for patients,
professionals and the NHS consists of two books and this resource is aimed at
professionals and managers in PCTs, GP practices and also hospitals. Book 1
gives a concise overview of the 'why, what and how' of medicines management,
and is aimed primarily at senior NHS managers. Book 2 is a more detailed
reference source and will be of most value 'to those individuals who have
direct responsibilities for developing and delivering effective medicines
management services for patients in practice.' See either
www.npc.co.uk
or www.npcrdc.man.ac.uk. Should be an essential
read!
Local Pharmaceutical Services (LPS) Pilots are now go with
guidance notes being issued on the 26th April. Pharmacy in the Future set out
the vision for these equivalents to Personal Medical Services (PMS) pilots. For
Community Pharmacy it is about providing patients with the right care at the
right time in the right way and of the right quality. Key objectives are about
better access, medicines management and service redesign around patients and
LPS will provide a means of contracting at local level for the provision of
pharmaceutical and other services within the same contract. Dispensing of
medicines is a core activity of all LPS pilots but other elements can be
proposed. The first wave of pilots will begin this year.
More information ->
Prof. James Raftery, Prof. of
Health Economics, University of Birmingham, in the HSJ (25/4/02) has an article
on the Performance Assessment Framework (PAF). One of the High Level
Performance Indicators vis-à-vis efficiency is generic prescribing.
"Generic prescribing has been important in controlling drug costs…The
increase in both prescription volume and costs over recent years, often for new
drugs, has been possible within tight budgets due to heavy reliance on generic
prescribing rather than branded drugs….the higher costof generics and the
current high level at 73.6% of all GP prescribing no longer automatically saves
costs." However 'cash releasing efficiency savings' are still the name of the
game and I note that in a health service fact sheet put out by the Association
of Chartered Certified Accountants (ACCA) prescribing again is mentioned as a
key pressure point. NHS Finance Directors should seek to further increase
levels of generic prescribing, agree and extend formulary arrangements in
primary care and implement prescribing incentive schemes, the fact sheet
suggests. And finally here, April's Bandolier carries an article on Do
Formularies work? A literature search found no evidence either way in terms of
reducing costs or improving health outcomes. "Indeed what little Bandolier
could find suggested the opposite"……
Re generics, several
PCTs have recently voiced their concern over attempts to stave off patent
expiries by introducing 'line extensions'. Hampshire PCTs have written to
several companies warning that educational collaboration with them might be in
jeopardy if they continue to introduce new forms of stereoisotopes before
patents expire. In the letter, the PCTs make it clear that assumptions
concerning generic costs in the future are essential to balancing their
budgets. "The NHS does not have the capacity to actively sustain the market for
branded products past the patent expiry period. Indeed, the decision about the
amount of money made available for prescribing in primary care is based on the
assumption that savings are realised when popular drugs become available as
generics." Oh dear….
PCT Directors of Finance have said that
prescribing costs will be the biggest financial pressure facing PCTs this year
because of overspends last financial year. Uplift factors for 2003/3 are not
expected to be enough and drug costs are now seen as one of major underlying
pressures on the NHS and lie firmly in the area of 'risk management.'!….
Scotland
NICE and
the Scottish Intercollegiate Guidelines Network (SIGN) have signed a statement
on working together to produce clinical practice guidelines. One problem at the
moment is that SIGN, although it pioneered evidence-based guidelines (i.e. its
statements are ranked as to their clinical effectiveness according to the
'hierarchy of evidence'), does not yet include cost effectiveness, as do the
guidelines from NICE.
The Scottish Executive is setting up a new
advisory panel to review the management and decision-making in NHS Scotland.
Also a report from the Primary Care Modernisation Group suggests expanding the
role of the Local Healthcare Cooperatives (LHCCs). The CSBS is to perform
annual reviews on acute trusts after they found that many trusts do not have an
adequate understanding of clinical governance. For instance, few trusts had
policies to ensure clinical guidelines, such as those from SIGN, were
implemented. For the report.
More
information ->.
Wales
The National
Assembly for Wales is establishing an All Wales Medicines Strategy Group
(AWMSG) which will advise Jane Hutt, Minister for Health & Social Services,
on 'developments' in prescribing. So this is about strategic medicines
management, horizon scanning, new drug introductions (it will not duplicate
NICE work!), NSFs, cost-effective prescribing and so on. Three pieces of good
news here - the meetings will be open to the public, there will be a public
annual report and, like the Scottish Medicines Consortium (SMC), the ABPI gets
a seat at the table. The National Assembly for Wales' Health & Social
Services Committee met recently. The agenda and papers can be obtained at
www.wales.gov.uk. The NAW has issued guidance to the
service to fund the implementation cost of NICE guidance and an extra
£10.5m has been included in next year's HA allocations. The Chief Medical
Officer has published her report.
More information ->. Also the Welsh Mental Health NSF is
due soon and it is expected to focus on Primary Care. The Chairs of the
proposed Local Health Boards have now been announced. See HSJ 2/5/02 p. 35.
About the
author
Therapy specific, corporate newsletters, written by
Alan Jones of AJC Healthcare, are employed within many
Sales Teams throughout the UK Pharmaceutical Industry, as a source of crucial
NHS intelligence.
To discuss how your team could benefit from regular
up-to-date analysis of the NHS changes and issues that directly impact on your
business, please contact
Alan Jones of ajc healthcare (alan.jones28@virgin.net)
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