NHS policy for 2024/25: strategy and engagement in a world of uncertainty (recorded in Jan 2024)

What do we know about plans and policy for 2024/25? As the expected central operating plan had not materialised (at time of recording), and with a general election and a potential Labour government on the horizon, how can NHS and industry drive forward improvements and innovation?

Host Robert Hull (Senior Consultant – NHS Insight & Interaction, Mtech Access) was joined by guest speakers Debbie Morgan (Director of Service Improvement and Transformation, Cambridge University Hospitals NHS Foundation Trust), Ellen Rule (Deputy CEO/Director of Strategy & Transformation, Gloucestershire Integrated Care Board) and Dr Viren Mehta (GP Partner, GP Federation Chief Officer, Viaduct Care). Together we explored what all this uncertainty means for NHS decision-making, day-to-day operations, strategy, and engagement with industry.

In this webinar, we bring together leaders from across the NHS to explore how they are planning and operating in this uncertainty.

We explore:
 - Strategy and planning in these times of uncertainty
 - What’s happening with GP contracts
 - Financial pressures and challenges
 - If/where it’s possible to drive forward change in the current environment
 - How Pharma and Medtech can best support NHS leaders
 - Where the panel would welcome solutions from industry

Please note this episode was first broadcast in January 2024 as a live webinar. Some aspects of policy discussed have evolved and continue to evolve.

Discover more at:  https://mtechaccess.co.uk/nhs-policy-for-2024-25/

Learn more about our NHS insights services at: https://mtechaccess.co.uk/uk-nhs-insights/

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Transcript

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- [Speaker] Welcome to this Mtech Access webinar. At Mtech Access we provide health economics and outcomes research and market access services from strategy through to implementation. Our unique NHS relationships guide and validate everything we do in the UK. We work with over 80 NHS associates to bring our pharmaceutical and Medtech clients authentic insights into the NHS. We can help you answer key questions related to the NHS, from how to communicate with integrated care systems, places and primary care networks, to how to capture pathways of care. Get in touch today to discuss your market access goals. First, though, I hope you enjoy the webinar.- Hello and welcome to this Mtech Access webinar. It's very exciting today to welcome you to this webinar. It's about NHS policy, sort of looking at 2024, 2025, particularly sort of strategy and engagement and the uncertainty that we currently find ourselves in particularly, in the NHS world. We're joined by three absolutely fantastic speakers today. Who I think are going to add some real insights and I can see that we've also got a lot of attendees from across both Medtech and Pharma as well as quite a lot of our NHS associates and other people from the NHS, I think we're quite a large and interesting audience here today. You guys have sent in quite a few questions, which I'm going to try and incorporate in, but we'll try and sort of, yeah, to stick to the themes. So it's my pleasure today to welcome our speakers. We have Debbie Morgan, who's a Director of Service Improvement and Transformation at the Cambridge University Hospital's NHS Foundation Trust. We have Ellen Rule, who's deputy CEO and Director of Strategy and Transformation, Gloucestershire ICB. And we have Dr. Viren Mehta, who's a GP Partner and GP Federation Chief Officer for Viaduct Care. So thank you all very much for agreeing to come and speak today. It'd be great to sort of hear a little bit about each of you and your background just in a sort of 30 seconds or so each. So if I go to you, Debbie first, just a quick introduction to yourself if that'd be possible.- Yeah, no problem at all. Delighted to be with you all this afternoon. So as Rob mentions, I'm Debbie Morgan, I'm the Director of Service improvement and Transformation at Cambridge University Hospitals and I've worked in a variety of different roles in my 30 plus years in the NHS. So I started off as a Clinical Site Geneticist so a Diagnostic Scientist and I've been at Director level now for over 13 years and really looking forward to the conversations that you have for us this afternoon. But in terms of my role, key bits are about building quality improvement capability and capacity across the organisation, supporting QI projects, but also heavily involved in productivity and efficiency for the organisation supporting colleagues with that.- Thank you so much. And just on Viren.- Hi everyone, I'm Viren Mehta. I'm a GP in Stockport, Greater Manchester. I've had a variety of roles as well. So previously I've been a Medical Director at CCG level, been responsible for prescribing and primary care. I've also been a Medical Director in a multi-specialty community provider as part of the new Models of Care programme. I've previous been a PCN Clinical Director and currently I'm chief executive of a GP Federation. So currently focused on delivery of primary care services kind of at Borough and at ICB level, but also still a GP at practise level as well.- Thank you. And over to you Ellen.- Thanks Rob. So I'm Ellen Rule and I'm director of Strategy and Transformation and Deputy CEO in Gloucestershire. I work in the Integrated Care Board. So we are largely concerned with improvement transformation of services across the system. I've got quite a varied background. I think I've worked in pretty much almost every part of the NHS except for maybe mental health services. I've worked in provider, acute roles, regulatory commissioning over about 20 years. And I'm also a health economist by training and have spent about 10 years sitting on national technology appraisal panels for NICE. So I've always had quite a strong interest in medicines and Medtech alongside my service transformation and improvement responsibilities.- Thank you. So I think we've got some excellent speakers to talk to this topic today. When we were initially planning this, we were thinking, okay, well usually around Christmas we get a nice big chunky policy document, a framework for the NHS to sort of build their strategy and their plans off for the coming year. But this year it didn't arrive on the 22nd of December. And so there's been quite a lot of, I guess a much greater extent of uncertainty about, you know, planning and where people should focus their efforts and their thinking. There have been some, you know, different approaches I think, you know, some people are relatively comfortable with that, some people much less so. But it'd be great to hear from you guys as to how that's impacted your thinking and your planning. And if I could come to Ellen first, actually, thank you.- So yes, we didn't get our usual Christmas present of planning guidance from NHS England, which will normally work with beta breath and has in the past actually arrived on Christmas Eve, but we didn't get that. So joking aside, I mean it is challenging and this is probably the latest I've ever known it to come through and it probably represents some of the really challenging discussions that will be happening at the national level around the reality of the resources that are going to be allocated to the NHS against the scale of the ask. So I think this is a triangulation that we in systems have to make every year around the requirements to deliver, which we can probably fairly clearly predict what they will be. So we know that the priorities the government have had are likely to continue to be the priorities that the government will have rightly around reducing elective waiting times and reducing the size of the post pandemic backlog that is still with us of course around delivering improvements in urgent and emergency care. I think we've seen a level of political interest in priorities such as ambulance handovers, delayed transfers of care from hospital. That is certainly of a level of detail that I've not witnessed really before over 20 odd years in the NHS. A very operational level of focus that is coming through right from the very top of the political shop all the way through into providers and systems. There are behind those really high priority measures, a whole raft of things that still apply for us to deliver against that are set out in the NHS long-term plan. I think at the point that at one point I counted them and there's around about 350 things that are important that systems should deliver. So it's a very wide brief and the requirements of the NHS long-term plan still exist, although it is certainly true that not all priorities are created equal in the eyes of the sort of regulatory regime and the performance regime that we are all subject to. So I think we probably can estimate the size of the ask, what is the more challenging side of that coin is the amount of funding that's going to go with it. And we all expect that to be highly challenged in terms of meeting the pressures of performance in an environment where we have so many cost pressures now, many of which are present in the wider economy. You know, all of our facilities are experiencing inflationary pressures, we see inflationary pressures on medicines. I mean that's actually been reported recently in the media, hasn't it? Quite extensively. Pressures such as no cheaper stock obtainable. The pressures on supply chain, all of those pressures translating through into cost increases. I think productivity challenges, costs of workforce, costs of running our facilities, all of these costs are going upwards and that the short version of that is that we are fully expecting our allocation will not meet just the basic inflationary pressure that we have. And then if you lay on top the cost of performance improvements such as making up backlogs in elective care and so on, we think we're going to be in an extremely challenging position and we're going to be needing to make some difficult choices about what we can and can't proceed with. I'll pause because I've probably given you a bit of a long download and others might want add some thought.- Yeah, Ellen, oh sorry. No, Debbie. Does that match your experiences where you are, do you think? Or do you think you've a slightly different take?- Very much so. I completely concur with what Ellen was saying, that sort of that typical sort of, we absolutely can make all of those predictions that Ellen has said and very much see that they are going to be priority areas or continue to be the priority areas. I think just sort of honing in on something that Ellen mentioned around the finances and productivity and sort of the challenges there. So we are currently going through our round of business planning, so basically looking at sort of what we believe to be the financial envelopes that we will need across the organisation. And at present we know that the sort of the things we would like to take forward are unaffordable in their totality. So as Ellen mentioned, the productivity aspect is hugely challenging. We knew that the next financial year was going to be challenging, but because the financial envelope hasn't yet been clarified from the centre, we've got that level of uncertainty. We cannot finish business planning. We don't know what the full level of costings are going to be, but we absolutely do know that the size of the productivity ask for us is more challenging than it ever has been. So that's I think sort of potentially an area for us to explore this afternoon in terms of where Medtech can potentially help. But, being an ever the optimist, where there are challenges, there are huge opportunities, but it does mean that we need to look at doing things differently. I think that very much then plays into service redesign, quality improvement, how we can transform and absolutely do things differently.- Thank you. That's a, yeah, very pertinent points. There will be opportunities I think we'll touch on those a little bit later, but Viren is do you see the same in primary care land?- So yeah, I think, I mean I sit on our provider partnership in locality board at place level. So I think, the first, I suppose dynamic that's new in our new world of ICBs is that relationship between the ICB and its places. So yeah, allocations and our set at ICB level, what that means for each place is kind of the next level of discussion, which is really difficult when there's so much uncertainty in the system. So that's an extra layer of conversations that kind of didn't need to happen before that do need to happen now and every ICB approaches that, you know, with the kind of individual circumstances within that footprint. So that's kind of a, it's very difficult I think for ICBs to have those conversations at place level until there's some certainty about what the expectations of the ICB are. I think the other added layer of complexity, I suppose is some of those elements of specialised commissioning where again, there's so much uncertainty about what exactly the direction of travel might be. I think lots of people have assumed certain things, but again, until you see it on paper in black and white, it's very difficult to kind of make those longer term plans. And that influences kind of ICB level conversations in all sorts of ways potentially. From a primary care perspective again, we're still, it feels like we're not going to see our next year sort of GP contract anytime in the near future. We're coming to the end of a five year GP contract, we're coming to the end of a five year PCN DES. There was a whole fanfare with the Fuller Stocktake around neighbourhoods, but we've not really heard anything of any clarity about what that neighbourhood model from a national perspective kind of what some of those intentions are, even though the word kind of integrated neighbourhood teams does feature quite heavily in sort of the national rhetoric. I think what's almost as interesting as, you know, what we haven't received yet, I suppose is looking back over the past 12, 18 months around what hasn't really featured in terms of national policy and strategy. So we had a major condition strategy sort of launched, but it didn't really say very much and we've not really heard anything further around that. Lots of people are concerned around cardiovascular disease and some of the population changes we're seeing in incidence and morbidity and mortality. But we haven't as yet heard really a strategy around it. Lots of people are talking about prevention and some of the sort of the lack of progress we've seen in some areas of prevention while the system is obviously understandably really focused on urgent care and elective, you know, it does feel like we don't really have the momentum that we once did around some areas of prevention. And I think the other things that have been talked about nationally around multi-morbidity and continuity of care again is something that we hear talked about but we haven't yet seen translated into policy. Whether they will come or whether it's one of those where next year is just kind of a year of carry on as the same is I suppose what we're all waiting to hear.- So I guess, yeah, it sounds like you're all dealing with the uncertainty as best you can and sort of, you know, rolling over contingencies and things like that. But Debbie maybe you could come back on those opportunities so you know when you are thinking, okay well you know, we're still going to have to reduce the backlog, we're still going to have to meet, you know, the targets that we were last year and probably there's going to be less money to do it. How do you decide what you're going to do in that scenario? How do you still bring new things in if you are and yeah it'd be great to hear a little bit more about that.- Yeah, so I'll maybe sort of give some examples to bring that to life but ultimately, it's about working with the clinical and operational teams as to sort of what they see as their areas of opportunity. Outpatients, I think what we're seeing, it's the triage aspect that is so critically important around does a patient actually need to come into secondary care? Can they be seen in an alternative setting? But also at that same time assessing which is the right clinician to see a patient? Does it actually need to be a doctor? And you know, quite often it doesn't need to be a doctor. So it's about transforming that pathway of care. Digital solutions, so what can we do to keep patients as well as we can do in their home environment, wherever that may be. So that sort of, that can potentially then help prevent exacerbations. That also then ties into how can we avoid where possible emergency admissions? So that whole bit about sort of keeping them as well as we can do within that home environment setting. I think there is a lot more that we can do around digital. So it could be around automation of processes so that so many of us do manual processes that could be automated, but it is also then looking at technologies. So whether it's sort of monitors that we can use by patients, we're doing a lot of that with our virtual ward. How we can actually extend the virtual ward in terms of providing care for our patients. And particularly thinking with Ellen and Viren, there's so much more that we can do across the ICS. So really looking at end-to-end pathways and I think it is going out of that sort of approach of looking at sort of silos. So it's really important for us to think about things from the patient's perspective and actually engaging with our patients that quite often we don't actually ask them what's going to make the best difference for them? What will help them and how can we put patients more in control of what's happening for them? And you know, thinking about my role that's where sort of quality improvement, using an improvement approach, how we can use our data. We've got a vast amount of data out there, whether it's the Getting it Right First Time aspects and using that to look at where we might have opportunities that we can then, as I said before, explore with our clinical and operational colleagues and be able to then help them to take those aspects forward.- Thank you. That's really interesting. Ellen, in your transformation roles in the ICB, are you looking at those sort of same areas? Is it large components of automation and pathway redesign or do you guys have a different approach to that?- So I would say that we're absolutely looking at pathway redesign. I think, I'm trying to think of a good example. I think we have, I mean we've got so many examples and I think we also have to be really mindful of thinking about where the real opportunities are for savings.'Cause I was just thinking about the comment around virtual wards and I'm the SRA for our virtual wards project in Gloucestershire amongst other things. And there's been a big national push to virtual wards, but equally there was a report published last week at some health economics analysis that suggests it might actually be quite expensive to look after people in virtual wards. And I think we have to be really, really careful not to treat some parts of our service in the NHS as a free good, particularly around primary care and some of our community services where perhaps we haven't traditionally had the kind of payment by results sense of counting each thing, but we can see there's this significant growth and there isn't really this translation of resources into primary care and community service or always to the same extent. And, but we've been looking at primary care in Gloucestershire and we have really strong primary care, but we can see the pressure is really, really intense in the primary care sector where it's something like 20% increase in activity since the pandemic. And I think where we've seen a shift into things like more channels, you know, we talk about channel shift and using things like telephone and online and so on. But I guess the caveat to that and some of the things we're exploring is that that perhaps doesn't divert demand but it adds, we increase the channels, we increase the expectation, we increase the availability and we increase the activity and primary care activity is up something like 20% in Gloucestershire, whereas we have productivity is actually down in some of our acute sector and so on. So I think I'm absolutely with pathway redesign, I'm absolutely with opportunities to do things with different parts of the workforce. But I think we have to think about that really, really carefully because sometimes hospital isn't a more expensive way if you know, there's sometimes an economy of scale where you're bringing people together that you can achieve and sometimes perhaps we just know more about those costs and we don't always see the other costs and the other impacts in our system. So I think as we're starting to develop our thinking, we are just being quite mindful of that in the way we approach pathway redesign. And I mean I, and there of course there are main opportunities for skill mix and where people, there's so many opportunities for that and where we could maybe look at different ways of seeing people that don't involve doctors that can certainly provide an opportunity. And also I think in terms of interests of the audience we've got here today, I think if Medtech can help us think about that as well and with new products, I think I've seen a few new things come into our purview recently where it's actually going the other way. So take for example the new innovation around some of the weight loss drugs, which obviously a lot of our patients are very interested in, our a bar has been set where you can only deliver those products and specialist services in secondary care and that's having several impacts on us. First we don't have lots of capacity in secondary care for people to get into to access those products. And secondly, a lot of those requests and questions go to primary care who also can't then facilitate the journey for the patient. So we end up creating a dissatisfied group of patients sitting with our GPs, which they very much don't thank us for who they can't get access to secondary care for, but who justifiably want access to that technology. Now sometimes that's obviously not just a decision of the company, but I think where possible, if we are thinking about new products, that's one of the things we have to be really mindful for. We're going to create a situation where that's going to be really hard for us to deliver, really hard for us to enable because we're setting the bar to a place where with the pressures we're feeling in secondary care capacity, primary care, etc, it's going to make us very hard for us to deliver that TA or that step change because of the way it's constructed and the pressures that we have with our services. So just offer that as a bit of a case study for where if Medtech are interested in where they can help think about it in the challenge is if we can keep the barrier as low as possible or the pathway as simple as possible, the number of steps as few as possible, that is always going to help us in terms of the implementation journey. So I haven't left too specific their role, but that just felt like a sort of personal example.- No, no, I think the examples are really useful and sort of definitely help with the understanding. Viren, I saw you nodding along to some of that and the pressures in primary care, they're obviously in the news quite a lot and you know, do you recognise that those pressures as sort of described there by Ellen and do you think there's, you know, what are you looking for in primary care to maybe help alleviate some of that? Are there sort of particular areas of innovation that you see real opportunity?- So yes, absolutely. I think across primary care, not just in general practise but community pharmacy and NHS dentistry we see on a day-to-day basis, these challenges. So I suppose in terms of how these challenges hit home, I suppose the first is the fact that the provider landscape in primary care is very different to secondary care. So you've got lots of small independent providers, you know, who are able to hold a deficit in the way that trusts can. So in terms of those financial pressures that are hitting now, that becomes much more real in an independent contractor world very quickly. So we are seeing a significant reduction in the number of GP practises across the country. Lots of community pharmacies closing obviously lots of NHS dentists moving to the private sector, which is a direct result I think, of the instability that those current challenges face. And I suppose we need to ask ourselves a question, what's the impact of that? And we don't do that very well. What's the wider impact of that? So actually if people can't access NHS dental care across the country, at some point we see the impact of that in oral surgery waiting lists and maxillofacial and in, you know, it's those wider longer term impacts that I think we're only now really starting to think about in more detail. I think the burning platform that we have currently does offer opportunity because it's forcing all of us to come together in systems in ways that we perhaps haven't been forced to do in the past. So, each organisation obviously thinks about productivity and efficiency, but actually it's the cross duplication that we, it's more difficult to measure that actually we're all being forced to look at. So, you know, thinking about some of our multi-morbidity sort of housebound patients who get several visits from lots of people in the system, you know, district nurse, a social worker, a GP lots of people will be putting that care in. So that idea of an approach with personalised care, that idea of case management in a better way, that actually putting proactive support in reduces some of that urgent demand if done properly, I think is something that is starting to build traction because people are starting to see the evidence base for it. And I think alongside duplication wastage in the system I think is another area that we really do need to look at both in terms of the impact on longer term climate change, but also in terms of that immediate financial opportunity that sits there. And I think medicines waste, I think most ICBs are really starting to focus on and improving the efficiency of prescribing I think is an area of a likely focus in the next 12 months.- So just to pick up on that point. Oh, so Debbie go first, and I'll pick up on something I wanted after that.- Yeah, I was just going to build on what Viren was saying around some of the sort of challenges and I think it would be remiss of me not to mention the industrial action. So that's, you know, going back to what Ellen was saying about the sort of clearing the backlog, of course with ongoing industrial action it just sort of ever compounds that issue and the impact that that means for our patients but also our staff as well because, you know, people are having to work very differently, covering shifts, etc. So I think it's that also acknowledgement just where our workforce are across the piece at the moment in terms of everything that is going on. I mean it's just absolutely unprecedented that it just seems to keep going. So again, thinking about sort of that from Medtech's perspective and how you engage with colleagues, obviously it's being mindful of what they're going through, but also sometimes people can't necessarily see the opportunity to do things differently because they're so embroiled in the here and now. So I think sort of the way that people engage with colleagues is really important that, you know, obviously it's about sort of identifying where there might be opportunities to make improvements for our patients, but also how we can actually help our staff, our colleagues to do things differently and make it easier for them. Which absolutely then ties into what Viren was saying around duplication. I think there is absolutely massive duplication across the system, but it's helping people to see where there might be those opportunities if they're just sort of completely frazzled by what's going on at the moment.- Thank you, that's very important and particularly on the workforce side and then the pressures that brings. One thing I just want to pick out of your bit Viren was, you mentioned prescribing and you know, there's been various pieces of work saying that prescribing has significantly increased through COVID and you know that there's ongoing difficulties in managing those prescribing budgets. What would you think companies should be thinking about in those terms? Can you speak to that at all and you know, should they expect budgets do you think to stay where they are or is that maybe a bit outside of your expertise on that?- No, absolutely. So I think ICB level when you're looking, so I think from an ICB perspective, quite a lot of costs are costs that really end up getting often shunted around the system and actually you're moving things from a cost and activity from secondary care to primary care to community care. From an ICB perspective and from an NHS England perspective, you know, if people are prescribing less, that's a genuine saving immediately on the NHS budget. So I think we do need to be, I suppose fully cognisant to the fact that it's understandable that ICBs will be looking at that. I think therein lies, you know, that people within ICBs and people working in systems, it's about the choices that you make. So, you know, as I said, looking at waste for me is one area where actually we're not reducing care to anyone because these are prescriptions and medications that often don't make their way into people's bodies and therefore aren't having a clinical benefit rather than cutting and reducing kind of particular drugs on the base of cost. So, you know, we know that up to 20% of medicines actually are never taken. That's a huge opportunity and a huge saving for any ICB looking in that area. One area that I think lots of areas are looking at are sort of, we recognise now with electronic prescribing lots of medications are uncollected from the pharmacy but yet are dispensed. So is that a potential opportunity for us? Thinking about prescribing along a pathway. So actually, sometimes actually prescribing more earlier in a pathway is exactly the right thing to do and optimising people earlier. So some of the new initiatives we've seen around CVD for example is exactly, you know, rather than that incremental increase in medication actually do we optimise someone much earlier on? Where I think systems need support is to understand the long-term impact of that. So, when we're doing a sort of cost benefit analysis, often I would say the NHS isn't particularly good at doing that by itself. Actually, I think quite often there's support. So for example, if you're looking at something that is managing somebody's cardiovascular risk and reducing heart attacks and strokes in the future, yes we're very good at costing the potential saving in terms of a hospital admission, but actually what's the wider societal cost of that? Because we absolutely need to be building that into our decision making better than we currently do in terms of days lost, so building in social care costs to that building in loss to the economy. And I think it's really interesting when you look at investment in the NHS, you know, the sort of analysis that that's been done by groups like Carnall Farrar do show that actually in terms of the wider economy, investment in the NHS is actually one of the best investments you can probably make in terms of a local economy. Yet, we are in this place where, you know, we do know that's going to be difficult certainly in the near future.- So, just to carry that on what can companies be doing to demonstrate that their new medicine, or piece of Medtech, or what have you, what should they be bringing to you? It sounds like maybe that health economics might be an interesting piece there, but are there other other bits of evidence or maybe just expand on that one? So what are you guys looking for as decision makers to make that decision? Go to Ellen first.- I'm happy to start. So yes, I think we do want to see cost benefit analysis, of course we do. Although I will say as a health economist I do find that quite often the claims are quite high and we don't need to always see really ambitious claims for there to be a benefit. So I do sometimes think even in the kind of stuff that we get presented from NICE, of course it is not really taking account of the real world detriment that we would get compared to the conditions in trials. So I think we do want that but we always know that we need to take it with a bit of a pinch of salt. But I think we want that. I think we also, I mentioned the point about where it is possible and it's not always possible, but let's try to think about the setting of care. So if we can be thinking about not tying products too closely to certain requirements, that helps us with implementation and because not all systems are the same and we will have different ways that we want to meet the needs of the patient. So I think you've seen some and we've seen some real innovation around things like home-based dialysis, home-based chemotherapy, different models for giving infusions, moving things to tablets from infusions, you know, all of these things are good ideas, innovative ideas that help us reduce costs and give us flexibility in the way we can offer. I think increasingly, I took part in a presentation recently about wearable technology and how that's going to be something I think increasingly that we're going to see coming and opportunities for tools that patients can use. And we see that already with some things where there's online tools to support the way that people might use various products, drugs, etc. And I think that's quite interesting to think about how we might support self management patient information. Because I think we could do a lot better than the kind of really densely printed leaflet you typically get in a box which Viren probably spends his life trying to explain or knowing that his patients don't really read. So ways we could make that information much more accessible and support patients to self-manage. Although I do have a slight fear that in 10 years time patients with comorbidities and multiple long-term conditions might be expected to have an arm full of smart watches, one for every one of their different products. And that might be become a bit confusing too, but we shouldn't assume that older people are not Medtech savvy and they might well be able, especially as we go forward to use the kind of monitoring apps and manage their care effectively. So you know, we've already got like some of the new things around diabetes and continuous glucose monitoring and there's apps and things that go with that and you can be sending your information in. I think this is much more the direction we're going to go and we haven't really talked about digital today, but that's also a huge challenge and opportunity for the NHS. It's a real challenge when you don't have really investment to put into that and an opportunity because we've got so much of an opportunity to improve. But you know, if we got to a place where we've got really well engaged patients who are active participants in managing their care who have access to things that can help manage and monitor their care and we can and some form of patient initiation around when they need to access things like follow up. I mean there's been some fantastic pilots around what we call PIFU, patient initiated follow-ups where you can see activity has really reduced. I was so digressing slightly, but we did a really interesting pilot in one service and it was fascinating because doctors were really worried, the consultants were really worried about PIFU and they thought the patients would be in all the time, but guess what? The patients actually found they had better things to do with their time and the activity reduced to about 20% of follow up around these long-term conditions when we gave patients the opportunity to access when it suited them and when they felt they needed it. But these were quite empowered patients with long-term conditions that they understood quite well. Obviously some patients may attend a lot but over time we found the activity really dropped. So I think there are opportunities around that and that more kind of enablement, empowerment and so on and support where you could be managing that direct could be things that innovation, Medtech, could start to think about supporting us with and we're going to have to think quite differently about that going into the future. And I think our younger generation expect to get things through apps and so on and increasingly will expect us to be able to support them in that way as well.- Thank you. Debbie could just to come to you on, you know, what are you looking for for that evidence piece and what do you want to see from companies when they're bringing things to you to meet the challenges that we've outlined here today or you know, or anything else?- Yeah, so very much sort of concur with what Ellen has said and sort of building on some of those points. So I think a clear articulation of what the patient benefits are. I think sort of being able to very simply sort of build on what are the cost benefits? You know are we transferring activity? You know, thinking because I'm based in secondary care. Is it going from an inpatient stay to day care to outpatient? Do we actually need to come into hospital? So we're essentially reducing unnecessary appointments. I think one thing we don't necessarily then think about is could there be a knock on negative impact for primary care? So if you're doing things in secondary care, it's that sort of the wallpaper and sort of does the bubble sort of splurge out somewhere else? Social care Viren mentioned and I think that is definitely something we're not necessarily very good at doing and those wider societal benefits that many people with long-term conditions, if you can get them back into work, they're then, you know, a taxpayer again and sort of those benefits. But certainly I don't think that's something that we necessarily join up as much as we could and should be doing. Ellen was mentioning about self-management, incredibly important for long-term conditions and we definitely need to be doing more around those side of things. I think something that we should be more mindful of is then the inequalities piece. So are there sort of, you know, we might be favouring one particular population, but what does that mean if you have a protected characteristic, there's some sort of health inequalities, how do we weave that forward? And from a digital perspective and certainly within our organisation we're wanting to use our electronic patient record more. We've got a patient portal. I think we will be seeing much more of that in terms of how patients then self-manage their own conditions. And just going off on a slight tangent, I think sort of something as well that we should be thinking about and many organisations particularly sort of large teaching hospitals is the innovation piece that Ellen did touch upon innovation, but that is becoming much more critically important and again, is something that Medtech colleagues can be thinking about in terms of potential angles of opportunity. A lot of organisations now have Executive Directors that have innovation within their portfolio. So again, just something to consider moving forward.- Yeah, I agree.- Thank you. Viren, do you broadly agree with those or is there things that we should be adding to that?- Yeah, no, absolutely. So I think in terms of that engagement between sort of industry and the NHS, I think firstly it's understanding the change in landscape and where decision makers now sit. So I think, over years people will have built relationships with, you know, meds optimization leads and CCGs, you know, the ICB landscape is very different and each ICB actually has taken a different approach to some of that decision making. Some is still very much place-based, but some is now much more centralised to ICB level. Increasingly we're seeing quite significant almost formulary decisions being taken at national level now. We've seen that within the PCN DES for really the first time in terms of, you know, GPs being very much directed to prescribe a particular product through the national contract. It'll be interesting to see what the future iteration of that, if anything looks like in terms of, so there becomes now lots of layers of influence that are needed in order to think about a decision. I think the other change in the way that it would be useful to consider, it's not just about the decision and the evidence itself. I think increasingly, you need to come to a system with support and idea around how you implement. And I think we've touched on this, you know, in discussions. So actually it's that consideration that it's not just about getting someone on a drug, it's how that happens. How you do that in a way that's cost effective, not in terms of just the drug itself, but to the wider system in terms of, you know, the number of steps that are needed before that can happen. And recognising that where there is that potential additional workload in one part of the system, there isn't that flex in the system that perhaps was there in the past. So asking any one extra thing, I think all of us are really conscious that it's really difficult to kind of have any extra expectations when everyone is already working, you know, well above capacity. I think absolutely that one of the areas that we've not really, really kind of explored, I think thinking about the NHS is patient activation and empowerment and over, you know, decades really what we've done is disempower patients and therefore we're now surprised that they come to us in greater and greater numbers. But for answers to things that perhaps elsewhere don't need a medical solution to. So de-medicalisation and de-prescribing and sort of bringing back that idea of activation, empowerment, and self-management is really important. And one of the key tools to that as people have touched on it is access to information. So part of that that what we've seen that paternalistic NHS approach is that we feel we hold all the information about our patient population where actually that idea that it's their data, they should be able to input into their own record with their own readings, be empowered to do that and therefore be able to take more control. And certainly with continuous glucose monitoring, that's something that I've seen myself in terms of that switch with patients of actually this is now my issue to control rather than I need to come to you to tell me exactly how much insulin to take. So I think, you know, that's where digital I think does have a real power in giving people that information about themselves in a way that they can understand and actually can lead to something that they can then do about it.- Just to pick up on that capacity piece, you know, with NHS teams essentially, you know, it's nose to the grindstone, so it's very difficult to look up and think now how can I write a business plan? How can I get through all the paperwork and dissuade people even if I think this is a great idea we might have some funding. Is that an area that industry can support? You know, would you guys look or be open to industry coming and saying, well I've got this, I can give you a case for change, I can give you a budget impact model or, you know, or is that less helpful? I'm going to go to the Viren, I think you put your hand up. Thank you.- So I think the thing that we all struggle with is head space and you know, if somebody can give me and my teams some head space to really think about some of that pathway redesign and some of those really complex decisions. So rather than a very quick snap decision that I have to make on the 10th email of the day, actually you have a bit of time to give some consideration. I think there's a lot of potential benefit and power in that, especially when we all work in complex systems where we need to bring those different voices together. So finding a way of creating head space I think would be for me something that if I could give to, you know, we know that our staff and our teams have solutions that just don't have the ability currently because of the lack of time and the lack of, you know, they're on their fifth task of the day when you have that conversation with them. So that would be one area I think that might be helpful to consider.- And what does giving your staff head space look like? Or is is that for industry to come up with? First take is Viren but Ellen or Debbie? Yeah. Go for it, Debbie.- So I think it's something around if there is a particular proposal around a change, being able to articulate that this will make it easier for you. So I think sort of sometimes people struggle we all get a multitude of emails that come through, but if you're able to, you know, something I sort of talk about is almost your elevator pitch around sort of what is it that will get someone to take note very quickly around the patient benefits and the staff benefits? So if it's something that will save you time, that will going back to what Viren was saying around sort of reducing duplication. Ellen's point earlier around that the money, the financial savings, so being able to give those headline figures, but you know, I think each pathway will be different in terms of what the potential benefits will be. So, it's articulating something in a way that as mentioned, someone will take notice and say actually this is just, you know, this is the right thing to be doing and this is actually going to make a difference. The other thing which can potentially help again goes back to something that Viren was saying around implementation. So if it's some support as to help him to take something forward and making sure that it does go into implementation, that can be very beneficial. I think generally, a skillset that seems to be missing across the board is project management certainly was in our organisation we are incredibly depleted around project management resource. So again, anything can that can help and that ties into the implementation piece.- Fantastic, thank you. So yeah, yeah, project management support, are you thinking sort of training for staff or are you thinking actually, you know, send us somebody who can come over and do some thinking with us and do the legwork?- Yeah, I think it is the latter. So again, if you try and do the training piece, people won't have time necessarily to do the training piece. So it is the hands-on helping us to move things forward, whatever is going to be most beneficial. As I say, each organisation, each system will have a nuance around that.- Thank you. Ellen, do you still see that at the ICB level as well? Would you be looking for sort of more staff supported by industry or do you think that's the wrong take for you?- It's an interesting question. I think despite, you know, there being the opportunity, I think we would be remiss in not saying there is still a degree of complexity in doing that and a degree of suspicion as well about kind of motivations what we all going to be getting from that and why might a company be wanting to help us. I mean I think I'm fundamentally a pragmatist that of course people would want to help us because there's something in it for them, but as long as there's something in it for me as well and we're all clear, then that's okay, isn't it? So as long as we've all understood the reasons why we're entering into that arrangement, then I think it's fine. But I do think that suspicions still exists. I think it's often easier for ICBs to engage where there's an intermediary. So I think we haven't really talked about them today, but the NHS set up AHSNs for a reason, which was to provide a vehicle for industry to engage with the NHS. Now I think it's not always clear how effective it is and it's different in different regions. Some of them are really effective, some perhaps have struggled a bit more. But I think where I have seen that work well we have worked through the AHSN as an intermediary. We had a project called don't wait to anticoagulate, which was around, particularly around the time we were implementing direct oral anticoagulants. And we did work with a industry partner there to help us around some of the use of tools, training, assessment of cost impact and so on. And some of the workarounds, was it having an impact on incidence of stroke? Which was actually one of the things I was thinking of when I was saying what the health economic model said and in reality, quite a disparity. However, it was really helpful to be able to do it with the AHSN as the kind of facilitating partner and they had the direct contract, if you like, with the industry provider, but we did it as a sort of three way. And the other thing that that would help in terms of the industry partners. So not only are they set up to work with industry, but one of the sort of rationales for the AHSN is also for adoption and spread. So they talked a lot about our don't wait to anticoagulate project on the sort of regional and national stage. So it gets a lot of coverage then. So I think that probably is still the most practical way to get direct relationship through ICBs, I think is via that AHSN kind of as an intermediary in my personal view because I think those bilateral arrangements are a bit hard to set up. But also you miss an opportunity for that more independent assessment of value. And if they believe that value to support adoption.- Thank you. For disclosure, I should said, I used to work in AHSN, but they've just rebranded themselves as Health Innovation Networks.- So perhaps you recognise-- I do recognise all the things that you've said there, but I can see it can be helpful to have that sort of middle ground to sort of help I guess ICBs and other NHS organisations, you know, say is this credible and worth my time? So I guess, yeah, it would be worth engaging with Health Innovation Networks. But I don't know, Viren have you had the same interactions or maybe with other organisations sort of helpful as a intermediary body?- Yeah, so I absolutely think so. We have a really good relationship between with our AHSN in terms of rollout of new treatments that they've really featured. And I think, yeah, again, I suppose another interesting change as we've moved from CCGs to ICBs is actually we've lost a whole load of non-executives within the system. And actually sometimes, you know, non medical persons often act, we're able to act as kind of honest brokers I suppose in conversations. And when you lose that, actually finding that honest broker who is able to approach that issue without a vested interest, I think is really important in conversations like this. So I think every system needs to think about how they do that, be it their AHSN, be that some of the intermediary. But I think Ellen is right. I think, you know, we need to, whilst, you know, everyone approaches these conversations with the right, usually with the right intent, it's very easy to fall foul, I suppose and be open to criticism unless you put those controls in place. So I think we all need to be open where in a world where, you know, things, decisions have to be made very quickly, expectations are very high, you know, you make a decision and you're onto the next thing very quickly. It's worth putting those controls in now as you start to have those conversations in different ways so that actually you've got the structures in place that you need.- Debbie, did you have anything to add there at all?- Yeah, just a couple of bits. So I'd go back to what I was mentioning around sort of, you know, many trusts now do have Executive Directors with innovation in their portfolio, certainly we do. Our ICS, they've got a Head of Innovation. So one of the things that's been happening across our system is establishing landing zones. So essentially a sort of a port of call for Medtech companies to be able to engage with organisations because I think it is sort of recognised that some organisations, it can be a little bit of a challenging thing to be able to do so in a consistent way. So I think it's just understanding at each system organisation, who those key individuals are, as Ellen mentioned, there's the AHSNs, some of them have been rebranded, but innovation seems to be the key thing that seems to be in that sort of title now.- Thank you. So we don't have very long left, so if I just went, go round again and just ask you, in these very uncertain times for the NHS and as you know, the wider economy, maybe the country as a whole, what would your sort of, if you could leave one thought with our audience today on, you know, how to bring new innovation into the NHS, what would it be? And if I go with Ellen first, then I'll go Viren and then Debbie.- Yeah, well I mean one of the things that's always good about joining these panels is you get to hear the other people speaking. And I was, you know, really struck by Viren's comments about the point about patient activation. And I think if we really think about the future, that has to change, doesn't it? Because we can't continue to live in this world where we live in an information age now and we can't, I don't think people, our patients will tolerate over the long term not having their own information, not being more in control of their own information. And I think people expect to get access to information very quickly and that if we don't manage that in a different way, we will just get overwhelmed with demand because we can't hold all the information here and expect, and people will come to us for everything. So I think if you think about what would the NHS sort of look like in the next 10 years, then the big innovation has to be around patient activation, empowerment, and how that is supported through Medtech and Pharma I think is really important. Because it's the biggest single use thing that happens in health services, that it's the number one product that people use is medicines. And a very significant proportion of our population, you know, more than 50% over a certain age, more than 70%, more than 80% use prescribed medicines. So the more we can think about how do we align prescribed medicines with this theme of patient activation and enablement and how technology can support us to do that? That for me, I think is a critical space in which Pharma probably have more head space to think about that than us. And I think it would be tremendously of benefit if we're to have sustainable and functioning health systems into the future.- Thank you. That's a great thought. Viren, did you want to go there or maybe go, where does your thought last thought go?- Yeah, so I suppose my last thought in terms of that interaction between the industry and the NHS, I think when proposals are brought, they need to be compelling and they need to be compelling to a wide number of audiences at once. And it's that triple, that very difficult triple aim of improving patients' lives and outcomes. Actually making staff's working lives easier or better in some way. And then obviously addressing kind of the long-term financial sustainability as well. And the argument now has to tick all of those three from the outset to even make it to kind of a consideration. So how you construct that argument, make it compelling, make it something that's very difficult to say no to, I think is the key thing there. And I think absolutely that idea of, so you know, I suppose how can we create a system where some of that suspicion and conflict is taken away, yet we can have really honest discussions about what the right thing is to do? So creating those systems, I suppose, from the outset that allows dialogue to take place in a way that perhaps we've shied from historically is I think something else that's worth considering.- Thank you so much. And Debbie?- Yeah, so I would build on Viren's point around the compelling piece. So it's really sort of being cognisant of the challenges that we're going through at the moment. So, you know, the waiting and times, the backlogs, and how we can continue to improve care for our patients and as Viren mentioned, improve things for our staff so that, how you portray that from a compelling piece will help people to really take notice and just being mindful of what our staff continue to go through. So being as succinct and as you can do, but as I mentioned before, where there are challenges, there are great opportunities.- Great, I think that's a really good point to end on. So thank you so much for all you three to be our panellists today. I think I've certainly learned a lot, and this has been a really good session. And thank you to all of our attendees who are able to come today. We hope to see you on our next webinar. So thank you very much, and goodbye for now.- [Speaker] Thank you for watching. If you'd like to find out more about our work with the NHS or how we could support your market access goals, please email info@mtechaccess.co.uk, or visit our website at mtechaccess.co.uk.