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All things Pharma

How will NHS reforms influence oncology prescribing?

Major changes are underway affecting the way the NHS commissions, funds and delivers cancer services, with big implications for pharma companies. Wilmington Healthcare’s Oli Hudson casts his eye over what is happening.


Cancer services are always a totemic issue in healthcare, and though political upheaval may yet interfere with Sajid Javid’s much-publicised plans for an “ambitious” 10-year cancer plan, improving how the NHS manages these services will no doubt remain a prominent part of the government’s reforming mission.

It is perhaps to be expected then that oncology is in line for a shake-up. Important shifts are already underway that will transform the way the NHS funds and commissions high-cost drugs, all of which will have important implications for oncology prescribing and the NHS’s commercial relationship with pharmaceutical companies.

New funding mechanisms

The first (and perhaps most important) of these involves funding flows. Most chemotherapy drugs are designated as specialised services, and have hitherto been funded nationally by NHS England, while high-cost novel cancer drugs were supported by the Cancer Drugs Fund, again funded centrally.

For non-specialised hospital drugs, meanwhile, Clinical Commissioning Groups (CCGs) had – until 2019 – been responsible for paying their costs via a ‘pass-through’ payment system whereby the cost of what was used by trusts was passed through to CCGs following BlueTeq approval, with medicines procured centrally by NHSE’s commercial medicines unit.

So, what is changing? We know that the Cancer Drugs Fund will remain in place, with £340million committed to fast-track new treatments into the NHS this year – the same amount will also be available through a new Innovative Medicines Fund for other novel drugs, bolstering the funding available to support a pipeline of novel therapies. However, there will be a number of shifts in the way commissioning and funding works for other high-cost drugs.

First, CCGs are in the process of being disbanded, to be replaced by Integrated Care Systems (ICSs), and there is a new blended payment mechanism in place for ICSs, which was established last year. This includes a fixed element to be disbursed by the new ICSs, which is intended to cover everything that would have previously been done under pass-through, including drugs, some of which were high-cost drugs (HCDs).

The second key change involves responsibility for specialised commissioning. The newly published Roadmap for Integrating Specialised Services paves the way for ICSs to assume responsibility for commissioning many of these services from next year, although there are a number of caveats (my recent LinkedIn post summarises some of them). 2022/23 is a transitional year, and NHSEI’s commissioning team will be working in partnership with ICSs on decisions, though no formal transfer of responsibility will happen before April 2023.

Taken together, these changes create a new funding landscape for oncology, centred around ICSs holding a ‘single pot’ of money, which brings together current CCG commissioning budgets, primary care budgets, the majority of specialised commissioning spend, the budgets for certain other directly commissioned services, as well as central support or sustainability funding, and nationally-held transformation funding that is allocated to systems. It is a huge shift in responsibility – and power – away from the centre.

New stakeholder networks

This will inevitably affect pharma’s stakeholder mapping. These changes, along with the statutory duties embedded in the Health and Care Act, formally establish ICSs – and Integrated Care Boards (ICBs) in particular – as the apex decision-makers in the new NHS. They will now hold the budgets, set the strategy, and oversee the delivery of the services for the populations they support.

However, ICSs sit on top of a much wider network of stakeholders and influencers that have the potential to make or break a product launch or brand strategy.

Much of the operational delivery of cancer services will, in practice, be done at ‘place’ – a level below ‘system’, covering a footprint similar to local authorities. In most cases, it will be driven by provider collaboratives, which bring together Trusts and other care providers to develop more integrated service plans across a system footprint, drawing on the priorities and direction set by the ICB. Understanding what is going on at place level, in terms of governance, formulary arrangements and the individual power brokers that shape decision-making, is key to securing market access.

It is equally important that pharma engages with the relevant clinical networks operating at different geographical levels within the NHS. I’ve already written a piece for PF Media describing why I believe these networks are such important players in the new NHS. From an oncology perspective, there are well-established Cancer Alliances in place at regional level and these will continue to play a vital role in shaping ICS/ICB thinking. They are particularly critical partners to work with for developing propositions that may have quality improvement and pathway implications.

New service models

And it should be stressed that pathway redesign is very much where pharma should be centring the conversation with its NHS customers. Operational and financial pressures, coupled with the experience of doing things differently during COVID, mean that NHS bodies are primed to develop bold and innovative solutions.

Some of these new service models are already taking shape. The backlog of cancer cases – with 40,000 fewer diagnoses and 300,000 fewer patients coming forward for diagnostic tests during COVID – has accelerated the development of community diagnostic centres, which have now achieved a landmark of delivering 1 million checks.

Technology is another important avenue of change, with a considerable drive around developing remote-monitoring solutions and, specifically, the development of virtual wards for vulnerable patients, including for oncology and palliative care patients as Norfolk and Norwich University Hospital is doing.

Many cancer services are also run through a ‘hub and spoke’ system, with prescribing decisions typically made by clinicians and senior pharmacist operating out of the ‘hub’ (typically a big teaching hospital) though the drugs themselves may be administered at the ‘spoke’ institution (which may be a smaller district general hospital).

What is abundantly clear, therefore, is that all commercial propositions will have to engage meaningfully with the operational realities and pain points of local services, as well as the strategic priorities set at ICS level. That might mean, for example, pinpointing how your offer can help to drive clinical efficiencies, or make better use of available workforce resources, or reduce the backlog and support elective recovery, and so on. As ever, knowing local circumstances is key.

New drivers

Finally, underpinning all of this is the drive to reduce health inequalities and improve population health. Already woven into the fabric of ICSs is a mission to “tackle inequalities in outcomes, experience and access”.

Industry has the means to become major players in this conversation. First, its data and expertise can help the NHS to understand disease prevalence and risk factors, allowing it to build a clinical strategy built around a clear view of how certain cancers may affect different communities or populations.

Pharma can also work with the NHS on new approaches to extending access to diagnostics for certain demographic and social groups who may be missing out on early treatment. It is also possible, using our prescribing data, to pinpoint variations in prescribing practices between specialist centres, which can expose potential disparities in access to leading-edge treatments.

Conclusion

Even at the best of times, oncology is a singularly complex healthcare area, covering a huge range of different cancers with more and more diagnostics and treatments – pharmacological, surgical, radiological, genetic – being adopted.

The four shifts underway, in terms of funding, stakeholders, service models and the strategic approach, add to that complexity and mean that industry must now engage with the NHS in a markedly different way.

In short, this requires a new conversation with the NHS – one that is increasingly data-driven, pathway – rather than product – oriented, and above all sympathetic to the stark operational pressures and new strategic parameters that NHS organisations will be working to.

Wilmington Healthcare’s specialist prescribing data, service and disease area insight, analysis, and consultancy can enable partnership and engagement with the NHS and help you tailor your value proposition to optimise your results. Find out more at https://wilmingtonhealthcare.com/what-we-do/healthcare-insight/oncology/

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Oli Hudson
Oli Hudson
Oli Hudson is Content Director at Wilmington Healthcare.

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