Commissioning - Health Committee Contents


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.


 
previous page contents next page

House of Commons home page Parliament home page House of Lords home page search page enquiries index

© Parliamentary copyright 2011
Prepared 21 January 2011