Written evidence from Abbott UK (COM 93)
INTRODUCTION
1. Abbott is pleased to have the opportunity
to respond to the Health Committee's inquiry into commissioning.
2. Abbott is a global, broad-based health care
company devoted to the discovery, development, manufacture and
marketing of pharmaceuticals and medical products, including nutritionals,
devices and diagnostics. The company employs more than 80,000
people and markets its products in more than 130 countries.
3. In addition to Abbott's expertise in
the health sector, we have also been particularly active over
the past few years in supporting research into the relationship
between health and work. We have sought to address key policy
questions such as how to build a more "work-focused"
NHS and ensure that patients' health needs are well supported
in the workplace.
4. Specific to this area of health and work,
Abbott's particular interest is in the field of musculoskeletal
disorders (MSDs), such as rheumatoid arthritis (RA) and ankylosing
spondylitis (AS), and psoriasis. MSDs are one of the most common
causes of work-limiting health problems and long-standing illness,
and the second biggest cause of sickness absence. (1) In 2007
Abbott supported a Work Foundation study into the effect of MSDs
on labour market participation—a project which is has bow
been rolled-out across Europe. (2)
5. The health and work debate poses a number
of questions for commissioning. Commissioners are expected to
deliver "more for less", by securing ambitious savings
to the health budget, whilst driving up quality and using their
resources "for the benefit of the whole community".
(3) Budget holders are being challenged to deliver both improved
clinical outcomes, and "patient-centred" outcomes which
take into account the impact of services on other factors—such
as ability to work, socialise, and maintain independence. These
issues are now more important than ever given the pressing need
to reduce the cost of ill-health to the public purse, and to retain
valuable skills and knowledge within the workforce to help drive
the UK's economic recovery.
6. Within the health sector Abbott also
has substantial expertise in managing malnutrition as well as
specialised commissioning for RSVirus for neonates.
CLINICAL ENGAGEMENT
IN COMMISSIONING
— In order to have sufficient expertise
to shape clinical services, participation in the GP National Education
Programme should be made a requirement for GP's professional development.
— There needs to be improved data on patient
populations to understand disease prevalence and commission services
appropriately. This could be encouraged through the CQUIN payment
system to identify what specialist and multidisciplinary services
patients need. An example of such a multidisciplinary service
can be found at the Department of Rheumatology in Bolton, which
aims to break down the boundaries between primary and secondary
care settings and whose staff includes consultants, advanced rheumatology
practitioners, physiotherapists, an occupational therapist, and
counsellors. An article outlining the Bolton case study has been
included with this submission.
— We were concerned by the findings of
the NAO report into Services for people with rheumatoid arthritis
that there continues to be a lack of integration between primary
and secondary care and little incentive for changing the way services
are currently configured.iv This follows a 2009 report by the
Arthritis and Musculoskeletal Alliance (ARMA) which highlighted
poor implementation of the Government's 2006 Musculoskeletal Services
Frameworkv, and a King's Fund report in 2009 which found that
"patients and professionals perceive an unacceptably wide
variation in the level and quality of care currently available".
(6)
— To minimise problems associated with
clinical practice variation, there should be greater incentives
to improve joined-up working between clinicians to ensure early
referral to an appropriate specialist. The NAO report into Services
for people with rheumatoid arthritis found that wider adoption
of Early Arthritis Clinics (EAC) could result in an initial cost
saving to primary care of about £3 million, with annual efficiency
savings for the NHS of about £2 million. (7)
— Helping people stay in, or return to
work would also require improved coordination between GP consortia
and local authorities. The Government should appoint a National
Clinical Director for MSDs who would provide strategic leadership
to ensure an integrated pathway, from securing early intervention
from GPs to appropriate secondary care such as in a multidisciplinary
team.
— Practices and consortia should be rewarded
for commissioning decisions that account for long term savings,
even if they incur initial costs in the short term—such
as increased spend on drugs that leads to long-term cost savings.
HOW OPEN
WILL THE
SYSTEM BE
TO NEW
ENTRANTS?
— The increased fragmentation of commissioning
carries the risk of greater inequity. GPs lack expertise in appropriate
allocation of the high-cost drugs budget, in the appropriate design
of early rheumatology clinics and other specialist services. This
will need to be carefully considered as plans go forward to implement
the new arrangements.
ACCOUNTABILITY FOR
COMMISSIONING DECISIONS
— Abbott supports greater involvement of
patient groups such as Arthritis and Musculoskeletal Alliance
(ARMA), the National Rheumatoid Arthritis Society (NRAS), the
National Ankylosing Spondylitis Society (NASS) and Crohn's and
Colitis UK. Community partners should also include employers and
business organisations to make sure that commissioning decisions
consider their needs—particularly around causes of sickness
absence.
— One of the key roles of the NHS Commissioning
Board will be the commissioning of Quality Standards from NICE.
Abbott believes that new Quality Standards on RA and other types
of inflammatory arthritis should be developed that incorporate
established best practice on supporting people to take part in
appropriate work, such as the 18-week Commissioning Pathway for
Inflammatory Arthritis.
— Abbott also recently supported an international
group of rheumatologists to develop recommendations aimed at the
improvement of the management of RA. Based on a shared decision
between patient and rheumatologist, "Treat to target"
included the measuring of the patient's Disease Activity Score
(DAS), which can reflect a person's ability to work. (8)
— At the same time, Abbott's work in the
health and work arena has led us to support the inclusion of wider
societal costs when assessing the benefits of treatment and technology.
NICE is not yet tasked with considering the wider impact of its
guidance on employment—a recommendation of the Health Select
Committee in 2007. (9) The Commissioning Board should commission
a cross-cutting Quality Standard on health interventions that
support work participation, including preventing co-morbidities
such as mental health and musculoskeletal disorders. (10)
— The NHS Commissioning Board will be central
to the development of a framework in which the social value of
commissioning can be articulated to GP consortia. This should
be managed on a national basis so that social outcomes are delivered,
such as appropriate work, with corresponding commissioning guidance.
— The NHS Commissioning Board should look
beyond health budgets. If the NHS board examined cost savings
that could be made outside of the department of health, such as
through reduced welfare payments, then it should encourage GP
consortia to look at this also. For example, the NAO recommended
that treatment of RA should be started as early as possible, ideally
within three months, and that initial cost increases to the NHS
due to higher expenditure on drugs and associated costs would
be offset by productivity gains of £31 million for the economy
due to reduced sick leave and unemployment. Whilst the savings
might lead to reduced spending from the Department of Work and
Pensions, the NHS Commissioning Board has a vital role in ensuring
a more strategic, joined-up approach to the UK's welfare system.
— In order to support local authorities
to commission a local HealthWatch, more data is needed on patient
populations, disease prevalence, prescribing variations and measuring
outcomes, such as return-to-work rates.
INTEGRATION OF
HEALTH AND
SOCIAL CARE
— Abbott supports the proposed integration
of health and social care as a means of evaluating the wider societal
impacts of disease areas and therefore applying the most cost
effective treatment pathway for patients.
- NICE should be given the remit to look at wider
societal costs and benefits. There should be a NICE quality standard
on health interventions that support work participation, and therefore
enable people to remain more independent at home.
— Integrated public service delivery, which
aims to reduce costs and increase efficiency, must also examine
costs and benefits which go beyond the NHS. The 2009 National
Audit Office report, Services for people with rheumatoid arthritis,
estimated that RA alone costs the NHS around £560 million
a year in healthcare costs, and that the additional cost to the
economy of sick leave and work-related disability is £1.8
billion a year. (11)
THE ROLE
OF LOCAL
AUTHORITIES IN
PUBLIC HEALTH
— Abbott looks forward to the proposed
Public Health White Paper. Whilst we support a joined-up approach,
there must be sufficient expertise available to local Health and
Wellbeing Boards—including around employment services.
— The Boards should bring together representatives
from employment services and the NHS in order to facilitate joint
planning and delivery of health services to support work participation
as part of the public health agenda—this could include occupational
health and physiotherapists, general practice and appropriate
specialist areas such as rheumatology and mental health.
— Health and Wellbeing Boards should also
include a council officer with a remit for economic development,
to ensure health services are commissioned appropriately to help
people remain in, or return to work.
RESOURCE ALLOCATION
— The issue of resource allocation again
highlights the need for improved data on patient populations,
so that resources are allocated to allow consortia to commission
services appropriate to need.
— GP consortia will need training/guidance
on the concepts of risk pooling at the appropriate level, otherwise
it appears likely that a disproportionate amount of money will
be held back from patient services as contingency for "insurance
risk".
— In addition, with the government being
explicit about the fact that there will be no "bailouts"
and that any failure will pave the way for other groups with vested
interests to take away the health care commissioning role from
a GP consortium, there needs to be assurances around service continuity
from a patient's perspective. The NHS Commissioning Board should
perhaps have oversight and responsibility around this.
SPECIALIST SERVICES
— There must be a greater focus on MSDs
in the list of Indicators for Quality Improvement, especially
with regard to the percentage of patients treated within three
months. Without a specific indicator for MSDs, for example, one
which ensures quick referral to a specialist or consultant, PCTs
are not currently incentivised to improve patient care.
— The NAO report on Services for people
with RA similarly argued that there is a lack of impetus or incentive
for changing the way services are currently configured.
— NICE commissioning guidance across the
immunology range should ensure specialist services are appropriately
integrated with other health and social care services—particularly
on earlier GP referrals.
— For some disease areas, such as the management
of Respiratory Syncytial Virus (RSV), significant regional variation
in clinical management and access to treatment exists. In such
cases, Abbott does not believe that existing commissioning structures
accurately reflect the needs of individual health economies and
exacerbate inequalities. Abbott would welcome a mechanism such
as that of the National Specialised Commissioning Group, whereby
local commissioners can come together on a national level to ensure
that appropriate services can be provided.
— The commissioning of specialist paediatric
services provides an example of how this approach is necessary.
Many children will have serious or complex needs which require
treatment by specialist paediatric services, working across discipline
and organisational boundaries. The complexities of these arrangements
necessitate flexible models to be established to meet individual
patient needs.
— It is important to recognise that conventional
reimbursement and commissioning models may not adequately reflect
the complexities of delivering paediatric care, and therefore
it is right that such services should remain under the specialised
commissioning umbrella.
# Abbott welcomes the recent recognition in Improving
access to medicines for NHS patientsxii that complex and specialist
conditions can benefit from greater use of collective commissioning
and decision-making arrangements.
October 2010
REFERENCES (1) http://www.hse.gov.uk/statistics/overall/hssh0708.pdf,
p 6, p 23.
(2) Data on File: Abbott UK, http://www.fitforworkeurope.eu/
(3) The NHS Constitution. Available at
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_093442.pdf.
p 12.
(4) National Audit Office, Services for
people with rheumatoid arthritis, 2009, p 10.
(5) Arthritis and Musculoskeletal Alliance,
Joint working? An audit of the implementation of the Department
of Health's musculoskeletal services framework, 2009, p 3—http://www.arma.uk.net/pdfs/MSF%20Review_FINAL1.pdf
(6) King's Fund, Perceptions of patients
and professionals on rheumatoid arthritis care, 2009, p 24—http://www.rheumatoid.org.uk/download.php?asset_id=615
(7) National Audit Office, Services for
people with rheumatoid arthritis: Economic models of identification
and treatment of early rheumatoid arthritis, 2009, p 16-17—http://www.nao.org.uk/idoc.ashx?docId=a5368598-d965-40f8-9ce6-0f9cfdc7b046&version=-1
(8) Annals of Rheumatic Diseases, http://ard.bmj.com/content/69/4/631.full?sid=f07443bc-ec46-4ee6-b6c5-0e9e83cae1d3
(9) House of Commons Health Committee,
National Institute for Health and Clinical Excellence, First Report
of Session 2007-08, volume 1, 2007, p 6—http://www.publications.parliament.uk/pa/cm200708/cmselect/cmhealth/27/27.pdf
(10) The Work Foundation, Exploring the
connection between physical and mental health conditions, 2010,
p 56 http://www.theworkfoundation.com/assets/docs/publications/260_body_soul160910FINAL.pdf
(11) National Audit Office, Services for
people with rheumatoid arthritis, 2009, p 5.
(12) Department of Health. Improving access
to medicines for NHS patients. A report for the Secretary of State
for Health by Professor Mike Richards CBE. 2008.
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