Advances in science and technology and year on year increases in funding have made a significant contribution to our ability to treat, manage and prevent disease. This success has led to increased longevity and a relatively active and prosperous older generation who provide an invaluable economic and social contribution to society. It has also contributed to what is arguably the most daunting challenge facing the UK health and social care system today - the need to care for and support growing numbers of medically complex, frailer older people with increasingly limited resources. As a result the current model of care for our most vulnerable members of society is at a tipping point and no longer fit for purpose.
Deloitte’s report titled ‘Better care for frail older people’ outlines the need to change the current health and social care delivery model to improve care for frail older people and explores how providers and commissioners can work differently to drive quality and efficiency and improve people’s experience in each place of care that they encounter.
The scale of the problem
Since 2010-11, real-term funding for healthcare in England has been almost flat against a background of increasing demand for services of around four per cent per annum, driven largely by an ageing population, whose number and prevalence of chronic disease is growing. At the same time social care support is reducing, restricted to those with substantial or critical needs. We estimate that current NHS and social care spend on the over 65s living with at least one long term condition is at least £30 billion a year. However this is spent largely on expensive acute intervention and residential care rather than on prevention, self-management, early intervention, and helping people live well and independently for longer. The number of people failed by the current system stands to increase considerably unless we act fast and adopt, as a matter of urgency, new models of care which address the current physical, mental and social care needs of our valuable, yet increasingly vulnerable, older generation.
Barriers to better services for frail elderly
Delivering the much needed change is challenging due to a number of entrenched barriers to better care, including:
- separate funding models for health and social care despite the fact that older people's needs are increasingly interdependent, with significant cultural and behavioural tensions undermining efforts to integrate and improve care
- fragmented care delivery with multiple groups of health and social care staff treating individual aspects of need in an un- coordinated manner when what is required is a shift towards treating the ‘whole patient’, facilitated by shared access to information at each place of care
- Limited supply of adequately trained and remunerated home care and care home staff who have the most contact hours but the least education and training – with almost 40 per cent of the 1.56 million social care staff having no relevant qualification
- capacity constraints in primary care with increasing demand for GP and practice nurse consultations and a workload in caring for the over 75s three times that of caring for the 45-64 age group
- health conditions exacerbated by unsuitable living conditions, with a third of people over 75 living in housing that has failed the decent homes standard, and low availability and affordability of extra care housing and care home places. This is compounded by the fact that half of all people over 75 live alone and are often socially isolated leading to chronic loneliness which is as bad for health as smoking 15 cigarettes a day.
The need to act to improve quality of care in all care settings is well publicised thanks to the many high profile national reviews and reports published over the last couple of years. However, exactly how the wheels of change will be set in motion is not yet clear especially given the difficulties prioritising, funding and implementing the long list of recommendations in these reports.
Improving the experience and outcomes for frail older people requires improvements on three fronts, physical and mental healthcare, social care and place of care. It also requires the redesign of services around the individual to enable them to live independently for as long as possible. This includes support in the community to allow prompt return home should admission to hospital or residential care be necessary. Our report outlines ways in which to achieve this goal, including new funding models which shift resources to primary, community and home care; supported by the wider adoption of technology; and access to better information, including patients medical records, for all those providing care. It also requires staff to work differently to forge sustainable partnerships and provide consistent coordinated services, 24/7.
None of this is rocket science, and indeed we are already seeing new models of care implemented in pockets of the UK which are revolutionising care for frail older people. However, the sheer scale of the challenge requires more immediate and widespread action to address the needs of increasing numbers of frail older people who aren’t in a position to wait for policy makers to take 5-10 years to develop the more integrated health and social care system that successive governments have agreed is the desired model of care.
Research Director, Deloitte UK Centre for Health Solutions
Last week saw a dramatic development in the Government’s handling of the NHS’s care.data project aimed at linking GP records to hospital records. Less than a month before starting to extract copies of everyone’s primary care records into a central database, NHS England has “paused” the project for six months so that they “can allow more time to build understanding of the benefits of using the information, what safeguards are in place, and how people can opt out”. This follows increasingly vocal opposition from the medical community (including the Royal College of GPs, the General Pharmaceutical Council and the British Medical Association), patient groups, the Information Commissioner’s Office (ICO), and an increasingly vociferous media campaign. Further fuel has been added to the flames by a number of GPs who have publicly declared their intentions to opt out and to advise their patients to opt out themselves.
Most of the worry is about how potentially sensitive patient information will be used, who will have access to it (and for what reasons), as well as its security. Such fears are not just hypothetical, given that examples of lost patient notes and what appear to be the misuse of sensitive patient information (even for the best of intentions) already exist. This has led many commentators to speculate whether the initiative might be permanently holed below the waterline by people opting out and, indeed, whether care.data might end up in the same political graveyard as the poll tax and the ID Cards scheme? With opt outs currently running at 5 per cent and rising, perhaps these concerns are well founded.
Understandably, confusion abounds and it’s hard for people to know how to opt out because the leaflet telling everyone was sent as unaddressed (junk) mail to every household (except for those who have opted out of receiving junk mail, who got nothing) and in any case the leaflet wasn’t clear on how to opt out. Confused? So is everyone else.
The ICO has consistently said that citizens should be asked for their informed consent before their personal records are used for purposes other than those for which they primarily exist. In other words they think the law requires an opt-in mechanism. There is quite a gap between this regulator’s position and the approach taken by NHS England the next six months will therefore be particularly challenging but also critical to the future delivery of healthcare.
It’s also easy to see why the general public is becoming increasingly concerned. Conversations with GPs are amongst the most private and personal of all conversations outside your family and friends, indeed sometimes more private even than those with close family. Pseudonymisation, in which all personal identifiers are replaced with meaningless codes, can be done to an existing NHS standard but there is an unresolved debate over whether it is feasible to do it at source before the information leaves the GP system. In addition, the more that the “open” data concept publishes and links large data sets, as is happening at an increasing rate across society generally, the greater the likelihood that a person can be re-identified by multiple other means. This suggests that any expectations that privacy can be maintained in the future may become unachievable and NHS England could find itself offering privacy just at the point where such privacy can no longer realistically be achieved. Things may well look very different in five years’ time, as no government can irrevocably commit all future governments to a particular course of action.
And yet this data is massively valuable clinically. As a nation we have very little idea of clinical cause and effect in primary care, whereas hospital episode statistics (HES) have been telling us for decades what works and what doesn’t in secondary care. Indeed, HES has provided significant benefits in terms of improving patient outcomes through analysis of hospital activities and performance. Moreover, there have been no recorded examples of data loss leading to patient or public harm, or the actual (as opposed to theoretical) identification of individual patients. There is game-changing potential in the use of this linked data, possibly more than enough to move the needle on NHS affordability. So (not for the first time) the interests of the population and the interests of the individual are tugging in opposite directions.
Research Director, Deloitte UK Centre for Health Solutions
Currently, at the national level, both private hospital ownership and the provision of private medical insurance (PMI) are highly concentrated with the five main hospital groups accounting for approximately 70 per cent of privately funded healthcare revenues in the UK. Last year, a complaint by Circle Partnership – an employee owned private hospital group – prompted an extensive review by the Competition Commission into the state of the UK private healthcare market and the value offered to its patients.
The initial investigation, published in August 2013, concluded that patients were losing out on competitive pricing due to lack of competition and high barriers to entry. This judgement didn’t go down well with private providers and since publication, the situation for these companies has improved slightly as the Competition Commission revised its stance and removed some rather unpopular recommendations such as a cap on charges and increased transparency. But divestment remains on the table.
So has private sector health become a victim of its own success? Chief executive and president of the world’s largest private healthcare company - Hospital Corporation of America (HCA) - Mike Neeb clearly thinks so as the Competition Commission insists he divests two London based hospitals, representing 30 per cent of UK revenues. While HCA stand to lose the most, should this forced divestment go ahead, they are not the only company to receive this news. BMI healthcare, the owner of 70 hospitals across the UK and employer of over 10,000 staff are also under pressure to divest 7 hospitals in various local markets.
Those under pressure to divest vow to resist until the bitter end using, if necessary, the Appeals Tribunal – where a number of Competition Commission decisions have been overturned. The majority of private healthcare providers, however, welcomed the measures to increase competition. Perhaps unsurprisingly, Insurers and smaller private health providers are strongly in favour of all measures and imply that more can be done to break the monopoly of the private heath market which they argue is costing patients as much as £200 million extra per year. They believe patient value for money can be improved through increased transparency measures and the reduction in negotiating power that large private healthcare providers have with medical insurers.
The prevailing view is that companies (UK and foreign) are queuing up take on attractive investments like private hospitals, but the question remains: will a change in ownership lead to a better deal for patients? BMI and HCA argue ‘No’. They consider that the original analysis is flawed as it underestimates the level of investment needed to install, operate and maintain world class health facilities. They also go a step further implying forced divestment sends a message to investors that the UK punishes success.
The assumption is that changing hospital ownership will lead to increased competition. In some areas, however there is no guarantee that this will be the case and indeed may simply result in a change in who owns the monopoly. Furthermore, there is an assumption that increased competition will result in price adjustments for end users – the patients. Whilst ownership may change the specific challenges faced by the hospital will not, so guaranteeing patient benefit is difficult. Even more so when you factor in insurers willingness to adjust premiums in line with cost of care.
So is the prescribed injection of competition justified? There are merits to both sides of the argument, but obtaining conclusive evidence either way is a difficult and time consuming process. What is clear is those involved are in it for the long haul – factoring in the inevitable appeals process – and a willingness to dedicate significant time and money to fight their corner. Ultimately, whatever the outcome of the Commission’s final report in April, the prospect of increased competition in the short term appears unlikely.
Research Director, Deloitte UK Centre for Health Solutions
First we had the internet, connecting people to information through emails and websites; then the development of social media and networks, connecting people to each other and encouraging us to reveal more about ourselves than we might previously have considered advisable. And now we are on the verge of the age of connectivity, connecting data analytics to the growing number of smart phones and other sensors that are increasingly second nature in our everyday lives. But with this connectivity comes an increase in personal data about us, both as individuals and as groups, on a scale never experienced before and which we are only just waking up to – both the good and the bad – as seen in the current controversy over the English care.data proposals.
Whether we like it or not, one thing is certain, over the next few years scientists, doctors, and the public will have access to more data about the human body than they ever imagined possible. Much of this has been driven by the development of the mobile health (mHealth) market. The proliferation in mHealth is partly a response to policy makers searching for innovative ways to reduce healthcare spending while improving the quality and quantity of care, and partly driven by patients’ desire for empowerment and convenience to manage their own health.
Indeed, the adoption of mHealth is growing exponentially in developing countries; where the lack of an expensive infrastructure creates freedom to innovate and allows providers to leapfrog obstacles in the use of technology that more developed countries struggle to overcome. These obstacles include cultural, financial and regulatory constraints, and are well documented; yet despite these constraints mHealth technology is slowly but surely changing the way physicians, patients, and other stakeholders interact. Examples include:
- GP e-Visits: Deloitte TMT predictions state in 2014, there will be 100 million GP eVisits globally (an increase of 400 percent from 2012 levels), saving over $5 billion annually compared to the cost of in-person visits. eVisit usage however is likely to be largest in North America where around half of the 600 million annual visits to general practitioners are generally for reasons that could also be solved by an eVisit.
- Remote rehabilitation – or telehabilitation - a relatively novel application that uses a computer game linked to a motion tracking computer mouse allowing patients the freedom to control their physical therapy from home. Use is currently being tested in patients with arthritis and balance and gait disorders and the approach is claimed to increase compliance and, improve recovery and, as a result, reduce costs.
- Using m-health applications to modify interactions between physicians and patients. Our TMT predictions report suggests that the highest year-on-year increases in smartphone penetration in developed countries will be among the over-55s, bringing a population with arguably the most to gain from m-health well in reach of its applications. Uses, in addition to monitoring vital signs, include sending photographs of skin conditions or injuries via smart phones to clinicians.
- Wearable technology, which can provide feedback on patient flow through the system, as well as improving reliability in delivering medication, assessments and diagnostics. It can also be used to support remote analysis of biomedical data for whole segments of the population, particularly the frail elderly, to enable more anticipatory care and patient monitoring to be done at a much larger and more efficient scale.
Whilst m-health can create convenience and possibly cost savings there are inevitably concerns at the impact it will have on quality of care. For example, e-visits have been shown to lead to an increase in antibiotic prescribing, at a time when control over such prescribing is key to reducing antibiotic resistance. But the evidence that better information improves quality is also important.
The case for m-health applications seems clear especially given the need to transform outdated models of working. Most healthcare policy makers and providers are waking up to this, however, confusion as to how to implement such initiatives and a lack of capital or willingness to invest continues to slow the adoption of mHealth. There is also the very real concern around data security and unauthorised access; an unintended consequence of health care’s digitisation and increased networked connectivity.
The question that remains therefore, is just how quickly will the potential of mHealth be realised in an industry that has traditionally struggled to embrace technology in its interface with service users? To realise this potential requires champions and leaders who fully understand the potential of connected technology and be willing to apply this to healthcare and, by taking away the burden of routine and functional aspects of healthcare, truly support staff to work differently.
Research Director, Deloitte UK Centre for Health Solutions
As seen in our recent report “Measuring the return on pharmaceutical innovation”, the majority of big pharma’s late stage pipeline value is driven by external sources: Acquisitions; joint ventures or in-licensing agreements. A trend that is likely to continue for the foreseeable future given the time, money and risks associated with bringing assets from discovery to launch, and the need for big pharma to keep pace with overall market growth. As quoted in our report M&A activity accounted for 22% of late stage pipeline value in 2013, looking ahead, what potential is there for big pharma to secure future R&D returns through M&A activity?
To start with, lets explore the general M&A environment. Analysis by Deloitte UK found overall M&A spend for FTSE 100 companies (excluding financial services companies) declined in 2013 after a revival of activity in 2012. Our analysis identified two types of corporate attitude and behaviour regarding cash accumulation that linked to M&A activity. The first involved stockpiling cash reserves – in reaction to the financial crisis – and adopting conservative M&A strategies. The second involved maintaining smaller cash reserves and, rather unexpectedly, adopting more aggressive M&A strategies. The diverging attitudes towards cash accumulation and spending were found to impact on company success with small cash holding companies experiencing higher revenue growth – partly explained by their M&A activity. To see the full report on “The Cash Paradox” click here.
So, how does big pharma compare in terms of corporate attitude towards cash accumulation and what is the potential to secure future R&D returns through M&A activity?
Overall the drug market reported increased M&A activity in 2013, however, big pharma’s contribution to this was an all-time low at just 18%. Whether this suggests a conservative, “large cash holding company” attitude or confidence in other sources of value to restore growth, it appears big pharma may be missing out on growth opportunities that smaller, M&A hungry companies, (big biotech and specialty pharma) are capitalising on. In doing so, these companies reported an impressive 50 per cent increase in market value last year compared to big pharma’s 25 per cent increase.
The growth differential between big pharma and big biotech/ specialty pharma companies presents two main challenges for big pharma should they decide to get back into the deal making game:
- the pool of potential acquisition targets is decreasing as high levels of growth (in value and, in turn, buy-out expectations) push more and more companies out of the affordable bracket for big pharma
- more competition as the ability of big biotech and specialty pharma companies to finance large M&A deals and compete on the same stage as big pharma increases
The net effect of both of these is a likely increase in the cost of M&A and yet further pressures on R&D returns. Throughout 2014 it will be interesting to see the extent to which big pharma re-enters the M&A game and how effectively this plays out. To keep pace with a growing market it’s clear all avenues of driving R&D returns demand attention however, as the M&A stakes increase, a safer bet might be to focus on spreading risk through in-licensing and co-development agreements.
Research Director, Deloitte UK Centre for Health Solutions
Last week, Professor Michael Porter, was the key note speaker at an influential conference organised by Reform. His opening remark that the NHS has the potential to be a world leader in developing value based healthcare, set the tone for a enervating conference. He argued that there is no healthcare system that isn't struggling but many are generating ideas and solutions - “same ingredients but different recipes” - and that there is an enormous amount that we can learn from each other. With that in mind, he set four challenges for the NHS.
The first was the need to identify the capacity to deliver a new healthcare vision and to define exactly what it should be delivering. He noted that the NHS is under the microscope as never before and that there was a need for someone or something thing to bring strategic coherence to the health economy. He noted that hospitals have to be coherent and cohesive but there are limits to what they can achieve alone and that horizontal integration can be highly effective. He recognised, however, that charges of anti-competitiveness had damaged plans for more horizontal integration and was concerned that Clinical Commissioning Groups (CCGs) might be too small and under- powered to effect the changes that are needed.
His second challenge was that CCGs need to be brave and lead on clinical reform and need clarity on what high quality care looks like. The third challenge was the urgent need for a solution to integration - a stubborn issue that has defeated successive governments for more than 30 years but one that he believes may finally have its moment in the sun. He also emphasised that it’s definitely not about structures but about incentives and enablers – in particular having an effective IT infrastructure and the need to resolve tensions between integration and competition. His fourth and final challenge was the need to improve the degree to which people manage their own care and to accept the importance of truly empowering patients.
Professor Porter argued convincingly that the NHS has many “structural assets” such as universal coverage and a single paymaster which gives it a real advantage over other healthcare systems. He then shared his suggested solutions to the above challenges, organised around six key pillars:
- Organise primary care into integrated practice units where care delivery is based on segmentation of the population and organised to meet the needs of the different groups. For example adopting a new philosophy for frail elderly people who need quick access to multi professional teams will mean practices becoming bigger and employing a wider range of professional skills.
- Measure outcomes (and not simply patient experience) combined with robust information on costs - and that determining a health outcome involves understanding the hierarchy of clinical and functional outcomes including time to recovery and sustainability.
- Reform payments to reward cycles of care – using patient level costing derived from activity based costing tools underpinned by a move to bundled payments for care cycles.
- Organise the system to deliver volume and address fragmentation - accepting the overwhelming evidence that excellence involves combining expertise and volume – and means stopping clinicians from doing things if they haven’t done enough to meet a minimum volume. It will also require helping patients understand that volume improves practice.
- Encourage excellent providers to expand geographically and for specialists to extend their geographic reach using a hub and spoke model.
- Build an enabling IT platform to support all of the above.
Given these ideas are already at the heart of the current debate in the UK the remaining speakers largely agreed on the direction of travel. Most described the need for co-ordinating care around the needs of patients, linking up health and social care and engaging patients as co-producers. There was a strong consensus that “outcomes” needed to be broader than “clinical outcomes” and the patient’s view of their experience was important in understanding the value of care, indeed that for end of life care the experience was the outcome!
It was widely accepted that integration is more than structures but is about aligning incentives and building teams with a common purpose. Moreover, that a more “sophisticated conversation” is needed on the role of competition and that patient choice should drive this conversation. Professor Robert Harris identified the importance of innovation and risk taking but that if an initiative fails that it should “fail fast with lessons learned”. He noted that the NHS has been a fair weather friend to industry and that if the NHS is finally to deliver value for money, there needs to be new types of partnership between the public and private sector, based on shared risk taking.
On reflection, I was left with the thought that the game changer will not be the type of health reform that is needed but how it will be achieved and importantly how patient-centered and coordinated it will be. Alan Milburn MP commented that a key skill missing from NHS science is public engagement and empowerment which are essential if the value agenda is to be finally delivered. While there was a sense that politics had obstructed reforms to local services in the past, there was now a greater degree of optimism that a more positive role for politicians is emerging to help reform services. Which only time will tell!
The slides from Professor Porter’s presentation are available here.
Research Director, Deloitte UK Centre for Health Solutions
According to the Federation of Indian Chambers of Commerce and Industry (FICCI), globally, India ranks third for pharma manufacturing volume and 14th in terms of value. In itself India represents a major market for pharma companies with a population of over 1.2 billion yet the country posts an impressive export turnover of over US$10 billion, spread across 200 countries. Domestic and international pharma companies, however, face a number of major issues, including drug quality, clinical trial quality and patent protection.
The World Health Organisation (WHO) estimates that up to 30 per cent of branded drugs sold in developing nations are counterfeit which can have profound implications for patients. For example, tuberculosis and Malaria counterfeits, which largely originate in India and China, are estimated to kill some 700,000 people a year! Counterfeiters, similar to legitimate drug manufactures, are keen to benefit from manufacturing costs in India that are around 40 per cent cheaper than other markets. As a result, India’s counterfeit market has reportedly grown at a rate of about 25 per cent per annum, and represents a significant proportion of the global counterfeit drug market (thought to be worth between $75 billion and $200 billion a year).
In response to the significant concerns raised by importers of Indian pharma products, the Indian Government, WHO, and the partnership for safe medicine (PSM) are putting in place initiatives to combat counterfeit drug manufacturing, including:
- upgrading the capacity of the state governments by equipping the state drug testing laboratories with modern technology and latest rapid testing equipment
- enforcing serialisation, non-clonable packaging and 2D barcoding
- investing in more ‘new drug manufacturer inspectors’.
The intention being to identify quality and safe medicines from spurious and unsafe medicines in the supply chain, and ensure prompt action against manufacturers and dealers found trading in fake and unsafe medicines.
In addition to the challenge of counterfeit manufacturers, legitimate manufacturers making up India’s booming pharmaceutical export industry are also attracting the attention of foreign regulators such as the FDA. It’s easy to see why as India is the biggest foreign supplier of medicines to the US and has about 200 FDA-approved drug manufacturing facilities. Indeed, India produces nearly 40 per cent of generic drugs and over-the-counter products and accounts for 10 per cent of finished dosages in the US. The FDA has highlighted a growing number of quality issues and last year added seven new inspectors to its India office, bringing the total number of staff to 19. Increased FDA oversight has led to some 19 drug manufacturing factories across India being barred from supplying medicines to the US. With restrictions, including import alerts imposed on the facilities of a number of life science multinationals.
Clinical trial quality
In many ways India is the ideal location to conduct clinical trials given its diverse pool of patients with diverse treatment needs and access to a large, scientifically skilled, workforce. This has caused huge growth in the number of clinical trials however, capacity to regulate trials has not kept pace leading to a number of unethical practices such as; a lack of patient compensation for adverse events; approval of drugs without clinical trials and lapses in informed consent procedures. Again increases in regulatory control by the Indian government, in the form of mandatory trial registration and the creation of numerous committees tasked with overseeing trial approval, trial execution, and ethical treatment of patients, is starting to have a more positive impact. The bad news is that delays in new drug approvals as a result of the new regulatory control regime is forcing some multinational companies to rethink their clinical trial activity in this market.
In India, 70 per cent of expenditure on healthcare is out-of-pocket, which has led the government and its judiciary to take steps to promote the use of generic products and prevent prices of lifesaving drugs being set by market forces. This has caused a number of issues for multinational companies, leading some to question the commercial viability of India:
- in April 2013, Novartis lost a six-year legal battle after the Supreme Court ruled that small changes to its leukemia drug Glivec would not get a new patent
- recently India upheld a compulsory license of Bayer's cancer drug Nexavar, effectively allowing generics firms to copy the patented drug
- the patent for Pfizer's cancer drug Sutent was revoked
- Roche's patent on Pegasys, a hepatitis C drug, was denied.
These challenges, amongst others, have caused pharmaceutical industry growth to slow over the last year (from 16.6 per cent to 9.8 per cent), a trend that both domestic and multinational companies are looking to reverse. For this to be achieved companies will need to work closely with the Indian government, regulators and other key stakeholders to establish compliant business practices that are commercially viable. Some of the solutions include:
- bolstering internal compliance to keep up with evolving global and domestic regulations concerning quality. This has the potential to drive significant competitive advantage
- striking a practical balance between underpinning clinical trials with scientifically and ethically correct practices and maintaining the low R&D costs that fueled initial growth in India’s pharmaceutical market
- striking a balance between ensuring affordability of, and access to life saving treatments with securing the future of innovative new medicines globally. Current patent laws have good intentions however, multinational companies, looking to emerging markets for growth as the price squeeze continues in traditional markets, have been left in a difficult position. Can the developed world continue to foot the bill for innovation? Increasingly it seems R&D engines need all the help they can get!
If India can adopt these solutions it has the potential to grow to a level that’s comparable (in value terms) to most developed markets by 2020 – something that pharma companies of today surely cannot ignore?
Research Director, Deloitte UK Centre for Health Solutions
With research provided by Mohit Maheshwari, Business Research Center Hydrabad
History does not reflect well on healthcare informatics. The massive National Programme for Information Technology (NPfIT) programme proved to be undeliverable and the loss of political backing at the end of the last decade resulted in it being wound down prematurely, leaving a legacy of some things done well, some partly and some not done at all. The key, essential, element that it was intended to deliver - the interoperable, shared electronic patient record - proved too challenging and was arguably its undoing.
Indeed, attempts to mandate a centralised programme ultimately led to a situation where the information systems and processes in the NHS in England ended up as a patchwork of many different types of computer system on a common, NHS-wide network. Whilst these systems generally provide much of the basic functionality that is needed locally, levels of interoperability between systems are low or non-existent. While digital records have now been implemented in the overwhelming majority of GP practices, NHS providers in hospitals and other settings are at different stages of digital maturity and many still rely on paper based records and have a substantial amount of work to do to provide clinical staff with easy access to the information needed to provide optimum levels of patient care. Furthermore, this lack of shared patient records constantly undermines the NHSs’ ability to deliver the much needed efficiency and productivity improvements.
The lack of access to patient records is most evident in our treatment of frail elderly patients who turn up at or are transported to their local Accident and Emergency Department with alarming regularity. On arrival, the lack of access to their full medical history means they are often admitted, diagnosed and treated for the admitting condition when better information about the complexity of their health needs could improve their treatment and reduce the scale of readmissions. Indeed, comprehensive information on the patient’s condition could help the NHS reduce the need for an emergency admission in the first instance.
In recognition of this urgent need for high quality data and information so that everybody can make the right decisions at the right time, NHS England have embarked on a series of initiatives to establish a new modern data service. The aim being to provide NHS organisations, citizens and researchers with accurate, timely information which, in turn, is expected to radically transform the way patients are treated and cared for. These include the flagship patient data service, care.data “linking” data from patients’ GP records to their hospital records by June 2014, and by 2015:
- enabling and supporting people to access and interact with their individual health records online
- re-launching the Choose and Book service to make eReferrals available to patients and health professionals for all secondary care
- enabling primary care providers to offer the facility to book GP appointments and order repeat prescriptions online
- supporting hospitals to implement safe and effective electronic prescribing services for their patients.
And by 2018:
- ensuring that integrated digital care records become universally available at the point of care for all clinical and care professionals
- a paperless NHS.
The Government and NHS have invested £1 billion in technology to improve patient care and ease pressure on A&E departments, including a £500 million Safer Hospitals, Safer Wards technology fund. One of the key things this money is intended for is a system that finally allows hospital staff, GP surgeries and out of hours doctors to share access to patients’ electronic records. By having this information at their fingertips the intention is that: staff should be able to spend more time seeing patients and less time filling in paperwork; errors should be reduced and drugs less likely to be prescribed incorrectly because patients’ paper notes have been lost.
The biggest challenge though is the Government’s requirement that the NHS should be paperless by 2018, which will require local clinicians and health services to come together to find innovative solutions for their patients. However, while the ambition is clear there are doubts that it can be realised. A recent technology survey by the Health Service Journal of 419 health and health IT professionals found that while most think it is a good idea, 91 per cent were concerned that NHS senior managers’ lack of knowledge about the clinical and cost benefits of improved IT systems could thwart the 2018 target date for a paperless NHS. With only 29 per cent thinking the target is realistic.
Ironically the lack of joined up working between different parts of the health and social care system is cited as the biggest single reason the sector could fail to achieve the health secretary’s ambition – ironic because the lack of a shared patient record and healthcare informatics is regularly cited as the main barrier to integration. Other reasons were cultural problems among staff, lack of funding and the lack of compatibility and integration between different IT systems.
For the sake of patients everywhere we have to hope that the ambitions for an information technology-based NHS does materialise, not only is it important for managing patient information more effectively, it is desperately needed to help deliver the NHS’s most pressing business outcomes. These include: integrated, joined-up care; improving the way the patient and healthcare providers interact, with greater patient involvement and shared decision making; and doing more for less, keeping the operational lights on in the face of a funding gap of 20 -30 per cent over next five years. Good healthcare informatics is essential, not optional, for the first two outcomes and will help massively with the third.
Research Director, Deloitte UK Centre for Health Solutions
2013 was the year that finally put quality ahead of finance as the overriding imperative for the NHS. The impetus for this was the February publication of the Francis Report and its conclusion that the Mid Staffordshire Trust had exhibited “a pervasive negative culture and tolerance of poor standards and that a host of organisations had failed to detect and remedy safety concerns that patients and the public had been trying to raise for years”. The repercussions were massive and were quickly followed by the Keogh review of 14 failing acute trusts that had been persistent outliers on mortality indicators. This was swiftly followed by enhanced Care Quality Commission (CQC) inspections of a further 12 trusts aimed at establishing a future inspection and rating system for hospitals. There was also a welcome increase in the attention given to nurse staffing as well as on the capability and capacity of urgent care services.
In November the Government’s full response to the Inquiry accepted, at least in principle, all but nine of Francis’s 290 recommendations. Key actions include:
- a tougher approach to the inspection and regulation of NHS organisations
- additional duties on providers and professionals to be open with patients in the event of a serious mistake and
- a range of centrally determined initiatives designed to develop the capability of individual organisations and the system as a whole to improve quality and safety.
These interventions also appeared to put the final nail in the coffin of the policy ambition to “Liberate the NHS”, especially given the news that the Prime Minister was requiring weekly briefings on the state of Accident and Emergency Departments’ performance and the Secretary of State’s weekly calls to Chief Executives of trusts that are struggling to cope. With an avalanche of media coverage about an NHS deemed to be in crisis, these latter interventions are in part a reflection of the Government’s real concerns that the NHS’s is unable to manage itself locally but also the need to show the voting public that they take seriously their fears about their most valued public service.
So what might 2014 have in store for the NHS? It seems likely that the perception that the NHS is in crisis will continue, fuelled by increasing media scrutiny in the run up to the 2015 election. There is already evidence that increasing numbers of NHS organisations are anticipating financial deficits in their 2013-14 accounts and that the NHS’s financial sustainability is likely to deteriorate further over the coming months. Furthermore, the much lauded ambition for a more locally responsive, integrated health and social care service is likely to flounder in the face of the continuing financial, cultural, and leadership challenges. Of key concern will be continued difficulties in accessing effective emergency and urgent care services, particularly for the increasing numbers of frail elderly people who will be feeling the impact of cuts in social services. It is also unlikely that CCGs will be able to make the much needed changes to the way they commission and fund services quickly enough, or reduce the unacceptable variations in performance seen across all four UK countries.
In 2014 clinical commissioning groups and health and well-being boards should start to feel more confident about flexing their combined muscles but how effective this will be will depend on local leadership and willingness to re-design services around the public and not around the professionals providing care. Meanwhile confusion over accountabilities will continue, provider organisations will need to focus their attention on responding to NHS England’s request for five year plans and strategies, while introducing 24/7 care and firefighting increasing demands for services. Specific issues that are likely to prove challenging include: increasing evidence of staff shortages; problems in meeting demand for primary care; delays in referrals to and in obtaining the results of diagnostic tests; increases in A&E and elective waiting times and in delayed discharges; as well as poor staff morale, recruitment and retention. Not to mention continued local resistance to much needed service reconfigurations.
There are however some positives that we can expect to see taking shape in 2014, which could, if adopted quickly and at scale, start to make a difference. These include:
- development of social, mobile, analytics and cloud tools to change how providers interact with patients and with each other, this will also drive new partnerships and collaborations
- improved access to personal health records and greater transparency over costs and outcomes should help to change peoples’ behaviours and their relationships with providers – helping patients to move from being passive recipients of care to become more active partners, who feel more confident in making choices and in self-management
- new ways of working and different staffing models to respond to the capacity and capability challenges facing the existing workforce. This will be helped by the adoption of new, increasingly competitively priced, mobile technology to create a more digital-savvy healthcare workforce that can leverage technology to engage more effectively with patients both in hospitals and in the community
- the development of precision medicine and a focus on specialty products means pharmaceutical companies will work differently with the NHS and will adopt new approaches to drug development, pricing and prescribing. Likewise, the development of companion diagnostics will result in new collaborative ways of working and more personalised medicines
- improving uptake of lower cost, more mobile diagnostic equipment will improve access to diagnostics and help develop new approaches to managing long-term conditions.
All of the above depend on finally embracing the use of technology in the health service’s interaction with service users. 2014 is undoubtedly going to be a challenging year for the NHS, for the industries that supply it and the patients that depend on it. But with adversity comes opportunity and those who are bold and prepared to take risks in adopting innovative approaches to healthcare delivery will have a lot to gain. More than £150 billion will be spent on meeting the healthcare needs of the UK population, finding ways to do this more efficiently and cost-effectively will not only improve the health and well-being of the population but will improve the standing and productivity of UK PLC.
Research Director, Deloitte UK Centre for Health Solutions
Innovating in the biopharmaceutical field is becoming more and more challenging. Our recent report, in conjunction with Thomson Reuters, clearly shows that some companies are successfully dealing with the current environment, while others are struggling to innovate. One of the key themes to come out of last week’s FT Global Pharmaceuticals and Biotechnology Conference was the need to shift from a therapy area focus to a focus on science – identifying specific pathways and targets, whether these be proteomic or epigenetic . This means first developing an understanding of the science of a specific biological pathway and then identifying the therapeutic areas that can be targeted through manipulation of this pathway. Many of the speakers highlighted how important targeting is becoming for any new life sciences drug; targeting the right science, targeting the right patients and targeting outcomes.
When it comes to targeting the right science, success in treating certain cancers is increasingly down to the ability of researchers to identify appropriate genetic or protein targets and subsequently develop therapies which interact with those targets to prevent disease onset or disease progression. One Nature Review paper highlighted at the conference examined factors driving R&D success and demonstrated that therapeutic areas are not in themselves a driver of success. The paper cites infectious diseases, on which a large amount of research has been focussed, as a positive indicator of success. In contrast a focus on neuroscience, which remains a poorly understood area of scientific research, was seen to exert a negative influence. What appeared to make the most difference was scientific acumen and good judgement, particularly with respect to earlier terminations and initiating proof of concept promptly.
In terms of targeting the right patients this has two key implications for the industry. Firstly, targeting the right patients typically means a companion diagnostic will be required. This involves not only identifying an appropriate therapeutic target, but ensuring that it is possible to identify a diagnostic marker for which a test can be developed.
The second implication of targeting specific patients is in terms of potential revenue generation. Targeting a discrete population of potential responders will likely mean lower volumes of patients. However, the upside for all stakeholders (the industry, regulators, payers, patients and physicians) is that patient outcomes are optimised and resources (money and time) are not wasted on patients who fail to respond.
The development of personalised medicines provides an opportunity for the industry and regulators to explore new ways of collaborating, which could benefit everyone. Furthermore, such therapies typically target areas of high unmet need, for which there is either no current treatment or treatments that fail to deliver effective results.
Targeting outcomes refers to utilising the vast amount of available real world data to track treatment response and provide insight into the clinical and social benefits offered by medicines. Ultimately this will aid in demonstrating the value of medicines and approval of reimbursement relative to this. Unlocking the potential of targeted outcomes requires the healthcare system to shift towards a more transparent and collaborative data sharing model, which will provide mutual benefit to all.
A number of speakers at the conference gave fascinating insights into the importance of following the science. These included breaking down internal divisions to ensure that pharmaceutical researchers and diagnostics experts can work together in an intellectual property (IP)-free environment, enabling R&D teams to look at therapeutic targets from a combined drug and diagnostic stance. Another approach was to simplify the organisational structure, change the attitudes of staff and develop much closer links to academia, creating innovation hubs which bring the company closer to science.
There was a lot of discussion at the conference about risk-sharing models, specifically around the area of adaptive licensing. Such mechanisms would allow innovative therapies to be launched earlier into the market, as long as agreement can be reached around potential risk, availability and pricing. The advantages to the industry include:
- gaining earlier marketing authorisation
- the ability to collect real world evidence by obtaining timely feedback on a therapy’s impact in the real world setting as opposed to using controlled clinical trials
- sharing risk with regulators
- removing the need for expensive and time-consuming late stage trials
- generating returns earlier in the development lifecycle
- more rapid uptake of innovation.
The advantages for patients, payers and regulators include:
- earlier access to innovative new medicines
- flexibility around pricing – the idea being as part of the risk-share, drugs are launched at a lower price
- real world data which is more reflective of patient outcomes is collected earlier
- the true value of the drug becomes apparent earlier.
Overall this suggests that the direction of travel for biopharmaceutical innovation should be a win-win for everyone concerned.
Senior Research Manager, Centre for Health Solutions