David Southern, managing director, Spirit Access, discusses how a more patient-focused pathway to designing services is more likely the successful one and how companies can achieve this.
Shoes
In the era of value-based healthcare, where Sustainability and Transformation Partnerships (STPs) in England are striving to reduce unwarranted variation in care, there is little doubt that the commercial models of UK pharma companies need to change.
The Efficiency Plan outlined in the Next Steps on the NHS Five Year Forward View (FYFV) cited the need for NHS organisations to get the best value out of medicines. However, recent research shows that NHS spending on medicines is growing at a faster rate than the total NHS budget.
The King’s Fund says that if the trend continues it could threaten patient access to innovative treatments. Clearly, despite sector-wide efforts to strengthen market access capabilities and demonstrate value, pharma has not yet designed the optimal approach. To progress, and to help NHS providers deliver value-based care, perhaps companies need to think more holistically.
The FYFV is about more than medicines optimisation. It mandates NHS organisations to reduce unwarranted variation, minimise avoidable demand and improve patient flow in acute care. Thankfully, pharma can help here too. With a broader focus beyond demonstrating product value, companies can help providers address wider efficiency challenges and, in the process, unlock meaningful value. However, to get there companies need to reimagine NHS engagement. Why? The development of sustainable models of care are not about products — they're about pathways. The most successful companies will therefore be those who think beyond the pill and take a pathway-led approach to designing services that meet their customers’ needs. The question is: how?
Service redesign
Service redesign has become a hot topic in UK pharma as companies recognise the value of collaborative engagement with NHS partners. However, despite efforts to carve out new ways of working with customers, companies too often revert to the traditional default of product-based detailing, fuelling engagement that’s misaligned with stakeholder needs. It’s understandable; companies boast great innovations that can alleviate disease and transform lives – why wouldn’t they place them at the heart of their engagement strategies? It all boils down to being customer-centric in defining value. Too often, the ‘solution sell’ is built on a narrow definition of value that doesn’t resonate with all stakeholders along the care pathway. It typically falls short.
To drive worthwhile change, companies need to understand what value means to all stakeholders. That definition will vary depending on who you are talking to and where they sit within the pathway. Companies must therefore map these stakeholders, identify their needs and understand what constitutes value in their environment. Moreover, they must use this understanding to develop dynamic stakeholder engagement strategies that address value in multiple ways – at the same time – to drive meaningful outcomes.
The rationale for pathway change is well understood. However, it can sometimes be poorly executed. So where do you begin? The key is to mirror the work of NHS commissioners and establish a dispassionate, patient-centred view of the pathway. This is fundamental to redesigning services. It’s where all thinking should start – laying down a baseline of current performance, what success looks like and how it can be measured.
Put simply, the patient pathway is a map of time and resources that patients consume when receiving treatment for their condition. It can be visualised as a flow diagram that illustrates the different activities at every touchpoint along the pathway. In most diseases, the optimal ways to treat patients are well established, with organisations like NICE and the Royal Colleges recommending standardised pathways of care. However, the dynamics of healthcare mean there are always gaps between gold standard pathways and the reality at the local level. Variation in resources and population needs, along with complex socio-economic factors and regional drivers, mean that companies need to look beyond NICE guidelines to design pathways that respond to local needs. Sustainable pathway change therefore depends on adopting a three-step process.
Step #1: Understand and prove the pathway
The first step is to develop a granular, end-to-end understanding of the patient pathway in your disease area to identify problems and opportunities. This primarily requires engaging with all the stakeholders along the pathway – not just the usual suspects. For example, recent work to redesign cataract services in Leicestershire was built around insight not only from ophthalmology consultants, clinicians and service managers but also theatre nurses, porters and receptionists. What’s more, it involved patients, pharma and device companies too. To be effective, stakeholder mapping must be open, collaborative and comprehensive.
It must also be supported by evidence. Developing the business case for pathway change requires establishing a robust benchmark of present-day performance and using that data to model new pathways. The industry can draw on huge datasets to understand and prove the patient pathway. For example, ICD and OPCS codes show the diseases and treatments assigned to individual patients in secondary care, whilst HRGs show the treatment costs to the NHS.
Primary care data is also crucial. GPs record diagnosis and activity using READ codes, though this can be harder to access. The challenge is to identify and integrate data from all these separate coding systems to develop a detailed picture of the current pathway.
Step #2: Develop models and simulations
The next step is to use intelligence captured in the mapping phase to develop simulations for new pathways that minimise waste and inefficiency. Ideally, companies should be thinking about this during Phase 3 development. An effective simulation will demonstrate how a remodelled pathway can drive positive change. However, it should focus on delivering value to the patient – rather than the institution delivering the pathway. Unlike institutions – which, as we’ve seen with PCTs, SHAs and now ACSs, fluctuate with policy – patient pathways are stable and provide common ground for all stakeholders. Simulations must be built using currencies that provide value to all these stakeholders, with everything converging around the patient. Robust simulations are a key component of evidence-based decision-making.
Step #3: Implement change through joint working
The final step – implementation – is crucial. The best-laid plans are often scuppered by passive behaviours where companies expect change to happen automatically. It never does. Pharmaceutical companies should be prepared to provide management capacity throughout the change process. This begins with developing and proving the business case for change and should evolve to support stakeholders through the communication and implementation phases. The development and management of a structured project plan is essential. A good implementation plan will detail the systems, resources and processes required in the new pathway – and connect actions and responsibilities with appropriate stakeholders. It will be underpinned by a commonly understood purpose and clearly defined metrics.
Collaboration is the key to success; joint working is about pursuing shared goals, openly and transparently. For pharma, this may also mean collaborating with independent partners that can help bridge the gap between industry, NHS stakeholders and patients. The best partners will have experience in NHS commissioning and service redesign – as well as robust simulations that evidence high-value pathway change.
However, you approach it, the message is simple: to unlock meaningful value, pharma must shift its focus from product-led detailing to pathway-led models of engagement. Ultimately, success is all about the pathway. And the pathway to value starts by walking in your customers’ shoes.