Clinical Reference Groups - they're here to stay!

Clinical Reference Groups (CRGs) were originally set up in 2011 to aid the transition of specialised services commissioning from the old NHS structure.  But now it’s been decided that CRGs are here to stay.  How well do you understand their role & their potential to influence clinical decisions?  And have you heard about the new ‘Medicines Optimisation’ CRG?   What are the implications for pharma?

When the NHS underwent it’s recent radical transformation, the Health and Social Care Act (2012) decreed that “prescribed services” will now be commissioned on a national level by the NHS Commissioning Board (now NHS England). 

However, what exactly are “prescribed services”?   The Act stipulated the four criteria which define these services and the Clinical Advisory Group for Prescribed Services (CAG) was then established to review the fit of the ‘old’ list of specialised services with these four criteria.   This body actually identified that the situation is nowhere near as simple as it first appears.  Ministers therefore agreed that they would need additional advice.  Hence Clinical Reference Groups (CRGs) were born.

CRGs brought together clinicians, commissioners, public health, patients and carers who all have  expertise in a particular specialised service area and who volunteered to develop service specifications and contract products for specialised (prescribed) services in the ‘new NHS’. 

Originally there were 60 CRGs.  Their work in the first year enabled NHS England to publish around 130 service specifications and 40 clinical commissioning policies for public consultation. 

The success of the CRGs has resulted in their further growth and development with CRGs now set to continue as the main source of clinical advice for NHS England specialised commissioning.   There are now 75 CRGs, and counting.  They will be responsible for developing:

·       Further service specifications which describe what NHS England expects to commission for the population of England in terms of standards and outcomes.  These will form part of the contract between commissioner and service provider;

·       Commissioning policies which describe the treatment that the NHS proposes to routinely commission for a defined patient group with a particular illness;

·       CQUINs to drive quality improvements through incentive schemes for providers;

·       QIPP plans for their particular service area; and

·        Identifying potential innovations with their service area;

·        Agreeing consistent measures of quality and provider performance; and

·        Developing a communication plan with organisations and stakeholders that have an interest in the work of the CRG.   Hopefully, this will provide more clarity about how the different groups in the new NHS landscape will interact and liaise with each other.

Each CRG can have up to 27 members:

·       A chair who is a clinical leader in the field of the specialised service. 

·       Representatives from each of the 12 clinical senates, with three representatives from London

·       Up to four patients or carers that have experience of the specialised service;

·       Up to four professional organisations that are involved in the training or professional leadership of clinical staff in the specialised service;

·       An accountable commissioner from NHS England; and

·       Area Team public health or pharmacy leads – depending on the needs of the work programme.
 

In discussions with Adelphi, CRG members have told us that things are MOVING FAST!

Whilst CRGs are not actual decision-making bodies, they are starting to have a considerable influence on the ‘look’ of specialised services.  Indeed, due to the enthusiasm and expertise of the CRG members, here at Adelphi, we believe that CRGs may become much more influential over the next year – in some cases, even starting to focus on national-level medicines utilisation decisions. This raises key questions such as if a Trust doesn’t abide by the recommendations of the CRG – will it actually get funding for the treatment from NHS England’s Local Area Team in future?

In contrast to what our CRG member advisors often anecdotally tell us, NHS England has stated that  ‘clinical advice related to drugs used in specialised services will be co-ordinated nationally by a specialised commissioning pharmacist in the Clinical Effectiveness Team collaborating with a pharmacist within each of the specialised commissioning Area Teams.’

Consequently, it will actually be the role of the Clinical Effectiveness Team to horizon scan for future NICE guidance that will impact on specialised services and to identify new NICE Interventional Procedure Guidance that may require clinical commissioning policies.  The team will then advise CRGs if service specifications or commissioning policies need to be reviewed.

However, in the past couple of weeks Adelphi has learned that there is a proposed ‘Medicines Optimisation CRG’ on the horizon.   This CRG is designed to provide medicines optimisation skills and expertise across specialist medicines commissioning.    Rumour has it that this CRG will produce a commissioning policy to cover all specialised drugs that are not on the Payment By Results tariff, with a more streamlined pricing structure.

With all this conflicting information it is not surprising that many stakeholders are confused and uncertain.

Regardless, it is a fact that the NHS prescribed services landscape is changing apace, so have you thought about what your strategy will be to stay ahead of the changes?  Do you know which, if any, of your products may be impacted by the activities of a CRG, and if so, which CRG and in what way?

At Adelphi, we have a proven fast-track to conducting interviews with CRG members around their focus and their vision.    We can help you to align your strategy with the NHS and make sure that you know who the key decision makers and influencers will be and what the processes will really look like.

Where to find the guidance

NHS England (formerly the NHS Commissioning Board) first published a guide for clinicians on Clinical Reference Groups for Specialised Services in January 2013.  This provided an overview of CRGs and explains how clinicians can get involved.  In March, NHS England published the guide for stakeholders.  This more recent document reflects the changes in number and make-up of the CRGs and explains how wider stakeholders can get involved in CRGs.  To read the guidance visit:

http://www.england.nhs.uk/resources/spec-comm-resources/

Health and Wellbeing Boards – what are they all about?

The Health and Social Care Act (2012) not only involved a major restructure of NHS commissioning but also required a strengthening of ‘local accountability’ under the auspices of local Health and Wellbeing Boards (H&WBs).  H&WBs are expected to be the ‘glue’ between healthcare services and social care but what will they actually do, how much power will they have, and what does this mean for industry?

Section 194 of the Act required every local authority to establish a H&WB for its area.  The statutory functions of the Board are to:

·         Prepare a Joint Strategic Needs Assessment (JSNA) and Joint Health and Wellbeing Strategy (JHWS) between the CCG and local authority;

·         Encourage integrated working between health and social care on commissioning, pooled budgets, and integrated provision of services

·         Undertake any other functions, which may have an impact on public health, as delegated by the council.

According to all the rhetoric, members of the H&WBs will work together in partnership to reduce the variation in both the quality of life and the life expectancy of their local population. The JSNA and subsequent development of the JHWS will provide the main focus for the H&WB.  The JSNA will highlight health and wealth inequalities in each area, such as areas of deprivation and levels of obesity, cancer, and other long term conditions.  The board will identify the current services and support organisations that they have in place, and use this information to develop commissioning plans within the JHWS.
 

In January 2011 the Department of Health invited local authorities to become ‘early implementer’ sites for the development of H&WBs – 138 out of 152 applied, so these bodies have been developing and starting to operate in shadow form since March 2011.  The remaining local authorities had to be operational in shadow form from April 2012.  As of April 2013 all boards have had to take on their statutory functions.  This would suggest that, like CCGs, some H&WB are currently more established and have built stronger relationships than others – and Adelphi’s own research confirms this hypothesis.

All the boards have a “core” membership as defined by the guidance – but our own research would suggest that the more developed boards have also appointed additional members such as representatives from the Police, secondary care organisations and NHS England’s local area team.

Adelphi has also identified that some – but by no means, all - of the boards are already demonstrating their willingness to be innovative.   For example, one London board has introduced a ‘Dragon’s Den’ type approach to decide on its priorities and key areas of investment.  Another board has appointed an   independent Chair that isn’t employed by the council or NHS to bring an entirely fresh perspective.

Our findings also suggest that, at least to start with, H&WBs will have a more preventative focus.  They will aim to address their local population’s health and wellbeing needs before they happen and before they require extensive treatment and resource. 

There is also the big question of how H&WBs will work with NHS England, who are responsible for commissioning all local primary care, dentistry and pharmacy services as well as specialised services.  At Adelphi we expect that this relationship will develop over the next year with the boards and the local area teams inevitably wrestling over the balance of power at the outset.

So what does all this mean for the pharmaceutical industry?   For example, does your company have products or service offerings that can support the work of the H&WBs?   Are your reps aware of the priorities and timescales for action of the H&WBs within their territory?   Do you know if the H&WBs are actually willing to work in partnership with industry?   Do you know where the balance of power will lie and who to target?

At Adelphi we have already undertaken extensive research with members of NHS England and H&WBs to identify their needs, wants, and motivations.  We are working with pharma clients to help them review their brands’ value propositions to bring the two together.  Have you considered what your approach to these new boards will be and how you might be able to leverage their priorities and activities to expand your market within this new environment?

Who is supporting the Health and Wellbeing Boards?

 

The responsibility for the ongoing development and support for H&WBs has been transferred from the Department of Health to the Local Government Association (LGA).  The LGA will support the boards by establishing a single information hub, providing a self-assessment framework, organising regional and national events to bring together members of different H&WBs, and supplying tailored support to individual boards that request it.  To find out more about the LGA click on the link:

http://www.local.gov.uk/

CCG Authorisation – what to make of different bills of health

As we’re all aware, the Clinical Commissioning Group (CCG) authorisation process was completed in March 2013 in readiness for the new commissioning model “going live” in England from 1^st April.   But  do you actually know the latest ‘scores on the doors’ and what it all might mean for pharma?

In the end, all 211 CCGs were given the green light to take up their statutory responsibilities for planning and commissioning hospital, community, and mental health services on behalf of their local areas.  However, there are various degrees of authorisation.

106 CCGs have now been fully authorised.  These will be able to fully function as a commissioner of local healthcare because they have been judged to have an entirely clean bill of health.  This includes a total of 43 who met all of the 119 authorisation criteria upon first assessment plus a further 63 who were able to formally discharge their conditions during the March re-assessment process.

91 CCGs have been authorised with conditions.  This means that they haven’t yet satisfied NHS England (formerly the NHS Commissioning Board) that they have met all of the authorisation criteria.  On the one hand, this might perhaps be because the CCG in question hasn’t yet submitted some of their paperwork. On the other, it could be something like the CCG hasn’t yet been able to recruit all members of its governing body – the secondary care doctor being a typical “gap” at this stage.  Moving forwards, these CCGs will be given a level of formal support from NHS England and the Area Teams and will be reviewed again later in the year.

14 CCGs have been authorised with legal directions.  This means their conditions are underpinned by legally-mandated intensive support from NHS England or another CCG. 

Adelphi’s recent recruit to the Spectrum team, Jo Pritchard, was directly involved in the authorisation process – personally moderating several of the CCG site visits which formed part of the assessment process.   Jo comments that the majority of these 14 CCGs failed to meet the authorisation criteria because they don’t have a three year strategy that is supported by a sound financial plan.   In other words, they cannot demonstrate that they can commission the services that their population requires within the budget that they have been given.

So now that CCGs are officially in charge of £65 billion of the £95 billion NHS budget, what does this mean for Industry?   For example, might pharma need to research which CCGs might be best to target or which are most ripe for partnership working?    And should brands be considering differential targeting strategies in accordance with the characteristics and/or priorities of the different CCGs?

These are very key and very timely considerations.  We know from research that there is a noteworthy difference in the attitudes and business potential of many of these CCGs.

Indeed, in order to succeed in this clinically-led commissioning environment, several of our more forward-thinking pharma clients are already conducting extensive MR to get to grips with the challenges of the new landscape. 

For example, exploring how best to segment CCGs for targeting purposes or testing various hypotheses on the optimum way to engage effectively with the NHS post the transition.  

The list of important MR topics is mounting with no two Adelphi clients investigating exactly the same angles and no stone remaining unturned.   Some exceedingly useful insights are emerging. 

All recognise that early knowledge of CCGs and the key players will be vital to inform effective marketing and customer engagement strategies.  

So the question is can your company really afford to miss the early boat?

Support for CCG Authorisation and beyond

NHS England, formerly known as the NHS Commissioning Board, have been responsible for the whole CCG authorisation process – from desktop review through to final decision regarding authorisation.  Support and guidance for CCGs will continue throughout the year. 
More information about the individual CCGs and the authorisation process can be found at the link below:

http://www.commissioningboard.nhs.uk/

 

Clinical Homecare – are you tapping into the opportunities for your brand?

As the health service undergoes a period of sustained reform, there is little doubt that clinical homecare is set to play a pivotal role in the move towards a more patient-focused NHS.  This growing sector also creates the opportunity for some pharmaceutical companies to really differentiate their brands.

So what do we actually mean by the “Clinical Homecare Market”?  In fact, the breadth of Clinical Homecare  has altered significantly over time.  Whilst the market started out primarily as a logistics proposition around medicines delivery, the sector has grown considerably in the past decade.  It now involves a whole spectrum of services, skills and competencies that are designed to manage and support patients in their homes – patients that might otherwise be likely to be treated in secondary care or another clinical setting. 

What’s more, the subject of Homecare is increasingly under the microscope, especially with the DH asking Mark Hackett, CEO of Southampton University Hospitals NHS Foundation Trust, to undertake a comprehensive review of homecare medicines in November 2011.   This led to the publication of the report “Homecare Medicines, Towards a Vision for the Future” – which amongst other things, concluded that the industry needs to work with the NHS to invest in technology to develop the homecare medicines supply market.  

Furthermore, with the Nicholson challenge putting immense pressure on the health service to deliver efficiency savings, it is acknowledged that clinical homecare has the potential to make a huge contribution.  This market therefore creates the ideal opportunity for both the NHS and the Industry to work in partnership and realise benefits for all the key stakeholders – patients, the NHS and pharma.

For the NHS, service designs involving personalised services such as Homecare come with the additional benefits of being able to introduce services which deliver BOTH cost savings and quality improvements and may also lead to better patient compliance – whilst at the same time, also successfully addressing the capacity challenges facing many local health economies. 

From the patient perspective, the Quality of Life benefits are clear – from practical advantages such as less travel, reduction in clinic time…to ultimately greater independence.

Pharmaceutical Companies with products/portfolios in therapy areas that align well to homecare also stand to benefit.   There are clear opportunities to demonstrate true product differentiation and provide real competitive advantage – to maybe achieve accelerated product sales and more market penetration. 

So does your brand have a Value Proposition that could incorporate Homecare to help ensure patients adhere to their medication, and/or prevent hospital admissions, and/or support early discharge from hospital, and/or be more convenient for patients? 

If so, what do payers and policy makers and other key NHS stakeholders think about your homecare proposition?  In a prescribing environment rife with market access issues, can you afford to ignore this avenue?    Should you be digging deep to uncover key insights to drive your homecare strategy?