Editor’s blog Monday 26 July 2010: Daft risk-sharing reimbursement, and Kings Fund on trouble even if £20 bn gap is less

I miss things; I really do. (Regular readers are probably aware of this).

This BBC News report on the complexities of the reimbursement for risk-sharing on expensive innovative medicines still took me aback.

How on earth did it seem like a good idea for anyone to leave the reimbursement application process to 152 different commissioning bodies, not to mention hundreds of acute providers?

I am a bear of very little brain, and long words bother me. Nonetheless, the concept that these medicines should each have a different reimbursement process, dealt with separately by every NHS commissioner and / or provider trust, is just stupid.

It also sends a sharp warning about bureaucracy in a world of n hundred GP commissioning consortia – ‘n’ being number yet to emerge.

Deep breath. It’s a national service. This use of expensive risk-shared medicines should be a part of specialised commissioning.

Leaving it up to each trust in the current manner is unjustifiable. Steve Williamson, consultant pharmacist at Northumbria Healthcare NHS Foundation Trust and co-author with David Thomson, lead pharmacist for Yorkshire Cancer Network of the survey published in Clinical Pharmacist, rightly told the BBC’s Emma Wilkinson that the NHS needed to set some basic templates for how such schemes should work rather than each company coming up with their own paperwork. Amen to that.

Meanwhile, Pharmaceutical Journal reports that NICE approves over 80% of treatments, 16% with optimising conditions and 67% within their licensed indications.

A smaller-than-expected funding gap remains a big NHS problem
Improving Productivity – More With The Same, Not More Of The Same by the Kings Fund’s John Appleby, Chris Ham, Candace Imison and Mark Jennings, while essentially an addition to the hallowed role of Things That Are Not Surprising, is a timely and welcome one. As well as being authoritative.

One aim of this document is to update the £20 billion funding gap financial assumptions made in the Fund and IFS’s influential 2009 ‘How Cold Will It Be?’ publication.

The new document suggests that now, “a total of £6.5 billion of cost pressures, including pay and prices, may either not be required or could be reduced in the light of national and local priorities. These pressures could be managed by constraining the growth in costs and limiting further improvements to the quality of care and waiting times”.

The Fund’s report continues:
- “As the NHS grapples with significantly smaller increases in funding from 2011, there is a danger that the necessary focus on improving productivity becomes, at best, an end in itself and, at worst, a misunderstanding that the NHS needs to dramatically cut budgets, reduce services for patients and sack staff. The NHS will need to carefully select the strategies which, together, produce more value from the same or similar resource – not the same for less.
- "There are real opportunities to tackle inefficiencies in support services and back-office functions. NHS organisations should also be developing and incentivising the workforce. This includes increasing productivity through the use of staff contracts, tackling sickness absence, and being more innovative in making skill-mix changes.
- "Many of the most signifi cant opportunities to improve productivity will come from focusing on clinical decision-making and reducing variations in clinical practice across the NHS. Reducing variations in clinical service delivery (as highlighted by the Better Care, Better Value Indicators) and improving safety and quality should be key priorities for providers. There is also an opportunity to improve the prescribing and management of drugs, which account for 12 per cent of the overall NHS budget.
- "For commissioners, there are critical decisions about the allocation of resources that have to be addressed in order to increase the added value for patients – improved health outcomes - from existing budgets. The key areas of focus should be reducing spending on low-value interventions, and redesigning pathways (especially for people with long-term conditions) to avoid unnecessary hospital admissions. Integrating care across health and social care boundaries is an important element of pathway redesign”.

It rightly concludes that “given the emphasis on reducing variations in clinical practice, the clinical microsystem is the most important area to focus on, engaging doctors, nurses, allied health professionals and others in delivering improvements in care”.

And with considered understatement, it adds of the current NHS redisorganisation of structure, “there is a major risk that NHS leaders will be distracted by organisational changes that will inevitably take place over the next two years, at the very time when there needs to be a single-minded focus on the issues set out in this paper”.