The 'new' NHS: What does it mean for pharma?

Leela Barham looks at the proposed reforms of the NHS in England and what they could mean for pharma’s relationship with commissioners

Equity and Excellence: Liberating the NHS and the draft Health and Social Care Act currently going through the UK Parliament have set out a blueprint for reform of the NHS in England.

Some have called it revolutionary, others evolutionary. No matter which of these interpretations you subscribe to, the reforms will change the relationship between the NHS and the pharmaceutical industry.

However, the entire process remains highly controversial and the final outcome—including the possibility of scrapping the reforms altogether, as some have called for—is still unknown.

If they go forward, one of the key reforms will be the proposal for GP commissioning consortia.

These will not be mandated in terms of size and structure (such as who sits on the board) but will allow GPs to decide how best to join together locally to spend NHS funds.

GPs will be responsible for some 60% to 80% of NHS funds, depending on the final allocations.

The key difference with the current approach is that GPs won’t be able to ‘opt in’ as they have done with practice-based commissioning (PBC).

PBC had allowed GPs to take on more commissioning responsibilities using an indicative practice budget.

But that will change. Instead, all GPs will have to belong to commissioning consortia.

And that, according to Shailen Rao, managing director of Soar Beyond, a specialist firm working on medicines management and service redesign in the NHS, is needed because “GPs play a vital role in determining use of NHS resources. Their decisions, in terms of both direct prescribing, but also their referrals, cost money. Making them accountable is therefore entirely appropriate.”

Evolving relationships

Whatever the final shape of the consortia, according to Bron Madson, head of media affairs at the Association of the British Pharmaceutical Industry (ABPI), “the industry has been working closely with representatives from the healthcare profession for many months to build on our evolving relationship so that whatever changes take place, we have a firm base from which to progress.”

GPs will become accountable for these funds at the same time as the NHS needs to save £20 billion over the next four to five years, a challenge that many fear the NHS will struggle to meet given declining productivity in recent years.

And, of course, questions remain about how GP commissioning consortia will link with proposals to change pricing and reimbursement of new medicines under value-based pricing (VBP). (For more on VBP, see

Is value-based pricing an aid to market access?’ and ‘Adherence and VBIDs: Delivering real patient value’.)

The new GP commissioning consortia are already forming; a number of pathfinders are already set up and will next year start work in a shadow form.

They won’t have legal powers to sign contracts until the Act has become law, and that may take some time.

These consortia vary enormously, from a single practice covering 14,000 people to 90 practices covering over 600,000 people.

Rao predicts that the smaller consortia will run their course relatively quickly, and that there will be activities consortia will want to work on together.

The debate is currently around which of the other professions, such as hospital doctors, should be involved.

Some see this as conflict of interest; others think the success of meeting the Quality, Innovation, Productivity and Prevention (QIPP) challenge means wholesale change and ‘smarter’ managing of patient pathways, which requires secondary as well primary care.

The challenge for pharma

For pharma, the challenge is engaging with clinicians across areas.

Those clinicians may or may not be working to the same goals if they can’t agree on commissioning priorities and pathways on their respective patches.

According to Rao, the government’s listening exercise over the summer, to reflect on the reforms, won’t change the underlying thrust of the GP commissioning consortia proposals.

“GPs are the right people given how they influence use of NHS resources,” Rao says, “and they have to be at the center of commissioning decisions.”

Seizing the opportunities from reform and QIPP will mean avoiding “doing the same,” according to Rao.

There are currently barriers to changing pathways and capitalizing on new medicines; Rao cites as an example the prohibition against offsetting from lower hospital admissions through investment in a care package that includes the use of medicines.

He says that so far, medicines management in primary care has been about “buying packets of medicine, which is too narrowly focused. It needs to shift to buying added-value services,” something which PBC has failed to systematically achieve across the whole of England.

Demonstrating value

Rao also thinks that, in some areas, key influencers on medicines procurement will remain the same.

That’s because consortia will want to join together for some activities, such as influencing prescribing in the local NHS hospital trust.

“Groups such as area prescribing committees may well still remain because it just doesn’t make sense to replicate,” Rao says.

According to Madson at the ABPI, “Regardless of who the industry is approaching, the key going forward is to demonstrate the broad value of innovative new medicines and how they benefit patient outcomes.”

So in some areas, pharma will be able to continue to work with the same people.

In areas where this has been a challenge, there may be scope to bring in learning.

Rao says he’s seen some real changes in the attitude of the NHS to pharma, and even more NHS people working directly for pharma companies.

To Rao, the reforms will ultimately be good for patients and for pharma, too: “Those companies that move to the business-to-business model will see greater uptake of their medicines.”

For more on the NHS reform process, join the sector’s other key players at Engage with the new NHS on September 27-28 in London.

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