HC 1048-III Health CommitteeWritten evidence from Bristol-Myers Squibb (PH 103)

Summary

BMS’s response is informed by a programme of work launched in March last year that relates solely to our virology portfolio. This programme has comprised extensive stakeholder outreach to clinicians, commissioners, patient groups, and other healthcare organisations, and has given us a clear idea both of the general public health challenges facing the NHS and those pertaining most directly to patients with HIV and viral hepatitis. It has also provided a unique insight into the commissioning of HIV and hepatitis services, how different service providers currently work together to deliver care to patients, and what further improvements need to be made to help achieve first-class outcomes for people with these conditions.

BMS agrees with the Government that a radical shift in how we tackle public health is required. We regularly see examples of innovation in public health, and frequently meet committed Healthcare Professionals (HCPs) in the course of our activities. This should be consistent throughout the NHS, and the Health Service should play a greater, more proactive, and more focused role in the promotion of public health. While BMS supports the movement to a leaner structure, this should focus on prevention, and then identify those at greatest risk, detect instances of poor health quickly, and deliver genuine improvements in patient care.

BMS is keen to work with all stakeholders in public health, including the Department of Health (DH), NHS, local authorities, clinicians and commissioners. It is hoped that the Government’s current programme of reform will result in a Health Service in which joint-working and seamless service integration are the norm, rather than the exception. To this end, BMS looks forward to the imminent publication of the DH’s plan for sexual health. It is hoped that this will put forward a vision of a comprehensive, integrated, and readily accessible, sexual health service across England that looks across the whole patient pathway. It should also align with other strategies the Government is publishing that have a locus on sexual health, including the National Liver Strategy.

The patient should be squarely at the centre of the Government’s reforms to the NHS: improvements in the quality of their care, and in their quality of life, should be the universal objective of all changes to the Health Service. BMS is therefore supportive of the principle of using outcome measures to encourage improvements in the delivery of care. These outcomes should be ambitious and unambiguous, and should be based on the outcomes that patients value, as well as those that reflect the particular nature of the conditions they have. This insight, that the DH and clinicians might value different outcomes to patients, surfaced at events we have recently held on both liver disease and HIV.

1. Commissioning and the future role of local government in public health

1.1 In September last year, BMS engaged stakeholders with an interest in HIV, including clinicians in primary and secondary care, commissioners and patient groups. The purpose was to ask how HIV services should be commissioned and delivered in the post-2014 NHS landscape, and how the transition to this end-point should be undertaken. The group’s overall view was that while it was definitely desirable in future for GPs and community-based providers to play a greater role in supporting people to manage their condition, it was unrealistic and inappropriate for HIV services to be commissioned by consortia in the short term. This viewpoint has since been endorsed by the Department of Health, and BMS welcomes the confirmation that the NHS Commissioning Board (NCB) will be responsible for HIV outpatient services, for the short-term at least. It is BMS’s view that it makes sense that specialised high-cost, low volume services should not be commissioned and carried out by individual consortia, and that expertise and financial risk for complex conditions should be pooled.

1.2 In February this year, BMS hosted a roundtable session with stakeholders (including the DH) with an interest in liver services. The delegates at the event included clinicians, commissioners and patient groups, and the objective was to elicit views on the impact of the proposed NHS reforms on liver treatment and commissioning and to identify the optimal model of care for patients with liver disease. The consensus view at the event was that there is severely limited understanding of how the commissioning of liver services will be organised in the new NHS. Delegates were also concerned by a lack of clarity around specialised commissioning for liver services in the new structure.

1.3 It is BMS’s view that further detail on the precise arrangements for commissioning sexual health services, particularly HIV and viral hepatitis, is needed. In particular, clarity is required about where responsibility for prevention and testing for HIV and viral hepatitis sits. The Government’s Public Health White Paper states that local authorities will be responsible for commissioning testing and treatment of STIs, although the NHS Commissioning Board will also be involved in commissioning services where efficiencies can be made by procuring at scale (eg drugs procurement). At present, therefore, it seems that testing would fall within the remit of local health and wellbeing boards in community settings and sexual health clinics. There is scepticism, particularly among the patient group community, that local authorities possess the skills, capacity or resource to commission an effective infrastructure for prevention and detection. There are also questions about who will commission testing in a primary setting. BMS would welcome reassurance from Government that localising responsibility for these services will not lead to a damaging fragmentation in the DH’s understanding of how infection rates are changing, and what measures work best in preventing the onward transmission of both diseases. BMS would also welcome certainty that separating the commissioning of HIV and viral hepatitis between the NHS Commissioning Board and local authorities will not hinder the delivery of joined-up services for patients with these conditions.

1.4 The capacity of local authorities to commission sexual health services is open to debate. BMS would, however, also welcome reassurance that devolving sexual health services to local authorities will not result in the politicisation of conditions like HIV and viral hepatitis, which are often stigmatised and misunderstood in the broader community. Local authorities have only limited experience in public health and none in commissioning. They will need to be supported to represent the needs of marginalised and excluded groups, many of whom are at particular risk of contracting conditions like HIV and viral hepatitis.

1.5 In light of the issues noted above, BMS would endorse the development of a sub-national level of commissioning for areas such as London, Birmingham, Manchester and Brighton, where concentrations of HIV and viral hepatitis are highest. These sub-national (or “supra-local”) arrangements would provide a compromise between a centralised approach which might seem remote from patients, and an overly parochial system, which lacks the expertise, resource and freedom from financial risk to commission suitable services. In such areas, we recommend that individual consortia pool the commissioning of their HIV and viral hepatitis services, working in partnership with a network of their Public Health Directors and Health and Wellbeing Boards to ensure any specific local issues are taken into consideration. There are already examples of successful joint commissioning of HIV services in the UK, such as the pan-London arrangements which are generally viewed as having driven up the standard of commissioning in the capital. BMS would like to see this model refined and replace the current assumed division of commissioning between the NHS Commissioning Board and local authorities.

1.6 In the next iteration of its plans for public health, the DH will need to ensure any new commissioning arrangements for viral hepatitis are clear, coherent and widely understood. Unlike HIV, there are currently no successful examples of commissioning for liver services, and no understanding of how commissioning in the new NHS will work. BMS would like to see the Sexual Health plan, National Liver Strategy and public health reforms provide clarity on how liver services will be commissioned after 2014.

1.7 BMS would welcome GPs playing a more active role in the Joint Strategic Needs Assessment (JSNA) process, and are supportive of the Government’s plans to make GP consortia responsible for preparing the JSNA in collaboration with local authorities. At present, this process largely ignores conditions that do not have a vocal and active patient population.

2. Public Health England

2.1 BMS supports the establishment of a national Public Health Service (Public Health England), and the recognition that public health requires a more proactive, preventative style of medicine and care than other conditions. It is hoped that Public Health England will adopt a robust approach to minimising the impacts of poor physical fitness and nutrition, as well as actively tackling conditions such as HIV and viral hepatitis, that often have cultural or behavioural roots. Even within a cash-constrained NHS, it will be important that Public Health England has sufficient resources to educate people about healthier living and healthy behaviours.

2.2 This notwithstanding, BMS believes that GPs and GP practices will continue to play a vitally important role in identifying current and future public health challenges, and providing advice about the most effective forms of treatment for conditions included within the definition of public health. They are the gatekeepers to the National Health Service, and should be encouraged to work actively with local authorities and with their local Directors of Public Health to ensure their patients’ needs are being addressed in a targeted and effective manner.

2.3 In addition, it will be incumbent for GPs to continue working with stakeholders such as patient groups, social workers, drug and rehabilitation councillors, and GUM clinics, to ensure that patients, no matter where or how they access the NHS, are staying on their treatment pathway. BMS would expect that the establishment of commissioning consortia will situate GPs in a much broader context than their surgery and immediate local environment, and will encourage them to develop broader networks of contacts, both horizontally (with other public health stakeholders in their community) and vertically (with secondary care clinicians).

2.4 There is no greater need for this than in the field of viral hepatitis. Patients with hepatitis B in this country generally receive a relatively poor standard of care. Awareness of the disease, and access to patient screening, is poor. Diagnosis rates are often low due to insufficient knowledge around markers of the disease and the implications of not managing the disease appropriately. Once patients are diagnosed, they may not be efficiently referred to specialists due to poorly defined (or non-existent) patient pathways. Once treated, patients may not be supported in adherence to their therapy in the long-term, as GPs are not incentivised or adequately informed to provide the appropriate support. In a recent workshop we held on liver disease (referred to above), the consensus view was that the best way to address these problems would be to give GPs greater support and training to identify at-risk patients. This could take the form of a simple checklist of symptoms, the inclusion of liver function tests in the Annual Health Check, and the publication of guidance on referral pathways. These simple measures, with appropriate reporting and data capture mechanisms, will help GPs monitor the prevalence of viral hepatitis in their local communities and provide important insights in treatment best practice to Public Health England.

3. The Public Health Outcomes Framework

3.1 As noted above, BMS is supportive of the principle of using outcomes measures to encourage improvements in the delivery of care. The aim of reducing avoidable mortality is to be welcomed, as is the NHS Outcomes Framework’s inclusion of preventing premature deaths from liver disease as a key national aim. The development of a “draft indicator” in the Public Health Outcomes Framework is also welcome. It is hoped that the next iteration of the DH’s plans will give due consideration to how this ambition will be monitored, and how services will be planned, commissioned and delivered in a structured and coordinated way. The deployment of a multi-disciplinary, network-led approach might be appropriate in this context.

3.2 The emphasis on reducing avoidable mortality as an outcome should lead to a renewed focus on prevention and testing. This is particularly important for HIV, which is currently excluded from the Outcomes Framework and therefore risks competition for ring-fenced public funding with issues like obesity and smoking, which are better understood and more familiar in a local setting. BMS therefore endorses the position of the National AIDS Trust, that the “proportion of persons presenting with HIV at a late stage of infection” should be developed as an indicator of improved clinical management within the Public Health Outcomes Framework. There are compelling arguments in favour of its inclusion. Late diagnosis accounts for at least a quarter of HIV related deaths in the UK (British HIV Association (BHIVA) mortality audit, 2006); in 2009, 52% of people with HIV were diagnosed late. The continuing failure to diagnose patients early prevents patients from receiving the most effective treatment, and increases the rate of onward transmission of HIV. Indeed a number of recent models have suggested that the majority of HIV transmissions are from the undiagnosed (see NAM, 2009). Reducing onward transmission rates also brings with it an unquestionable economic logic. According to the HPA’s 2010 HIV Annual Report, if all the 3,780 UK-acquired infections diagnosed in 2010 had been prevented, over £32 million annually or £1.2 billion over a lifetime in costs would have been saved.

3.3 An emphasis on prevention and testing in viral hepatitis is also necessary. At present, there is no screening programme for patients who are at risk from contracting this condition, and early diagnosis rates are poor. The DH should consider developing outcome measures such as the reduction in mortality from liver disease; improved rates of success of treatment; increased patients helped to manage and reduce risks; and more people with liver disease reporting improved quality of life. These were the recommendations of the delegates at the roundtable event hosted by BMS in February this year. In addition, it was suggested that the DH should establish process measures for commissioners in the field of viral hepatitis. Potential measures for consideration included more people being placed on treatment for viral hepatitis; improved early accurate diagnosis rates; more assessments taking place in primary care, and increased support for lifestyle changes.

3.4 It is hoped that success in achieving these outcome measures will be judged within an appropriate time-frame. While BMS can see the political desirability (both nationally and locally) of measuring outcomes on an annual basis, improvements in clinical management are often only apparent within a longer, two-to-three year period. Short-termism should not be allowed to compromise genuine improvements in the standard of care, and risk demotivating HCPs and patients alike.

3.5 BMS also suggests that outcomes should evolve over time as the DH and NHS improve the way they use this data to commission better services. They should remain open-minded about the process required to make this happen, all the while ensuring that the only outcome measures that are used reflect current public health priorities.

4. Funding

4.1 Over the next four years, the NHS will undergo historically unprecedented changes to its structure and methods of operation, and will be under pressure to deliver the necessary efficiency savings demanded by the QIPP agenda. The Government must ensure that rising healthcare inflation does not systematically erode the ring-fenced funding promised by the Government, and BMS would welcome clarification about how the DH will continue to protect public health spending, both nationally and locally, within this challenging economic context. This is particularly important in the field of sexual health, where evidence has been found in the past (Disturbing Symptoms, Terrence Higgins Trust, BHIVA, BASHH) of money being diverted away from sexual health to meet NHS deficits in other areas.

5. The Health Protection Agency, Public Health Observatories and surveillance

5.1 The provision of high quality care is, to an enormous extent, dependent on the quality of data – about disease prevalence, the effectiveness and cost-effectiveness of various interventions, and about patients themselves. On a daily basis, it is easy to see the negative impact that poor quality data can have on people with particular conditions. For example, information covering the number of patients diagnosed with viral hepatitis, how many have been initiated on treatment, how many have stopped their treatment, and how many have been referred does not exist. The DH must address these knowledge gaps if NHS reform is to deliver improved patient care, and BMS welcomes Public Health England’s commitment to quality and transparency in its approach to evidence.

5.2 Over the next year, the Department of Health has committed itself to developing a specialist workforce to gather information and intelligence on public health. In many areas, this will involve merging currently separate bodies, such as the Public Health Observatories and Health Protection Agency. BMS would welcome further clarification about the potential impact this transition period could have on the surveillance of complex conditions such as HIV and viral hepatitis. Public Health England’s desire to use the reform process to strengthen monitoring, surveillance and data mining is to be welcomed, but BMS would like reassurance that the vital role played by the HPA in monitoring HIV and viral hepatitis prevalence and diagnosis rates will not be compromised in the next few years. Indeed, this capacity should enhanced in the future, as part of the assessment of performance against any new outcomes measures. In particular, the improvement of national data to demonstrate variation in the provision of liver services should be developed, as should surveillance which points to the most effective and cost-effective interventions to manage viral hepatitis.

June 2011

Prepared 28th November 2011