Pharma Market Access Insights - from Mtech Access

Specialised Commissioning in the NHS – What do you need to know now

• Mtech Access • Season 2 • Episode 24

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The proposed new NHSE systems for specialised commissioning are arguably the highest risk of all current dynamics, both for the NHS and for suppliers. Key aspects or policy have been published in ways that are hard to access and even harder to interpret. Here, we gather an expert panel to discuss what proposed new NHSE systems for specialised commissioning mean in practice.

In this episode, we explore:
 - What’s new for Specialised Commissioning and what’s set to change?
 - What are the potential implications of the proposed changes recently published?
 - Integrated Care Boards (ICBs) and their increasing role with Specialised Commissioning
 - What this means for the NHS and for industry in practice

The episode begins with an overview and analysis of the changes from David Thorne (Principal Associate, Mtech Access and Business Development Director, Well Up North PCN). David then opens up a broader discussion about the implications of these changes with our guest panellists James Curtis (Deputy Operational Director, Gloucestershire NHS Foundation Trust) and Mohammed Asghar (ICS Prescribing Governance Lead at Frimley Health and Care ICS).

The episode was originally broadcast as a live webinar on 2nd December 2022.
Learn more at: https://mtechaccess.co.uk/specialised-commissioning-nhs/

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- 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.- Good afternoon everybody. Thanks very much for joining us. My name is David Thorne. I'm the chair for today. I'm just going to pause for literally a minute because of course people join us gradually as they click in, and we're expecting quite a number of people to join us today, which is very encouraging. But I'll just let them join us. So you might hear a slightly paused introduction from my speech here, but welcome to the session organized by Mtech Access. We're looking at Specialised Commissioning today. We're deliberately going to use NHS language and terminology. So we'll probably refer to this as Spec Comm. One of the questions we'll probably address today immediately is whether that's a correct title anymore. But I'm really looking forward to today. I enjoy doing these sessions. I'm particularly interested in what we're doing today because I think this is one of the most puzzling aspects of the current changes that we're going through. And I'm hoping to learn a lot from today. Lily, could you just move us onto the next slide please? One of the reasons I'm so positive about today, and I'm sure I'm going to learn things, is we've got two expert contributors today and I'm going to ask them to briefly introduce themselves. Mohammed, would you like to go first?- Thanks, David. Yeah, my name is Mohammed Asghar. I'm the Prescribing Governance Lead within Frimley Health and Care ICS with a background for many, many years working with the acute trust and dealing with commissioners back in the days of PCT, CCGs, etc. And having been poached a year or two back and now working for the ICS. So very interested in seeing where things will develop with the delegation of Spec Comm down to ICB level.- Thank you. Well, that's already opened a can of worms there Mohammed, even in your introduction, so I'm really already starting me off with questions. James, who are you?- So, hi, I'm James Curtis. I'm general manager for oncology hematology, palliative care, immunology screening and cancer services. So I've got quite a varied role that interacts with Specialised Commissioning in lots of different ways from screening all the through cancer services and their surgical aspects, and also clearly oncology and hematology. I've got 13 years of experience in the NHS, varying from PCT old days to public health and community as well.- Great. And those two brief introductions, they were like a exposition on the current NHS with its acronyms and its neologisms and its shared roles and it's multiple hats that people wear. But what we got is you can hear there are two cracking guys from different parts of the country who've got slightly different perspectives on a very, very important topic. If you don't know me, I'm David Thorne. I've got a career in the NHS and in industry. My NHS career at the moment is based around primary care, so not particularly focused on Specialised Commissioning. In the past I've been a director in a Commissioning organization and carried a Specialised Commissioning brief. And I can say immediately that Specialised Commissioning is a really intriguing area, yeah? So when I held the brief, I was just thinking last night in my preparation for this, the two most expensive things that I've bought under Specialised Commissioning that I was responsible for were, adult eating disorders and forensic psychiatry. So it's a really intriguing area. It's not just about the medicines, it's not just about devices. It's about all kinds of intriguing things. So Lily, next slide please.'Cause what I'm going to do is I'm going to go through some quick slides to bring us all up to speed. We're then going to hand over much fuller topic. We'll get off PowerPoint, get Mohammed and James back on. And one of the things I'm going to ask them to do is basically to critically appraise the slides I'm about to say, because I wasn't joking and I said, I'm really expecting to learn today. This is the most impactful known unknown of all the changes that are going on at the moment. So one of my objectives today is to help you out there. And we've got a record audience today. So you are clearly in the same boat as the three of us. What are the definite things? What's implied? When we forecast this through what can we expect? What does this mean, okay? The final bullet point on there is important. If you ask questions today, I'm going to also make sure with our panel, and it might limit some of what we say, we can't mention specific companies or specific medicines or devices today. So we might have to allude to certain areas. We might have to say ophthalmology or something like that. And you'll have to take it as red what we might be talking about, okay? So it does limit us a little bit on the compliance side. Next slide, Lily, please. And I will move through these quickly. This is really important. This is an area of high risk to you. It's probably the area of all the changes that has the most impact, where it is the most nebulous, that has the least detail. And again, that's the sort of thing I expect to see(James is making notes there) for James and Mohammed to come back to me and say,"No, you're wrong because actually it's this." Apologies if this patronizes anybody, but let's just go back to basics. Spec Comm is essentially an insurance scheme. So what you're doing, whether we were, Mohammed mentioned PCTs, CCGs, I go back to health authorities, we've always banded together at a certain level to try and organize services at a level that makes sense for the number of patients. So typically around phrases around Spec Comm like, to do with low volume and high cost. That's not always the case, but it's essentially an insurance scheme, hence the geographical spread of it. A significant element of specialised care actually sits outside Spec Comm. So if you imagine any patient journey of probably a period before they're diagnosed, often misdiagnosed, all kinds of tests that might take place, a progression of a disease, a progression through the system. There's elements of treatment, hopefully recovery then and people getting better. But when you actually map out somebody's care through everything from NHS 111 through various spells through treatment, and as I said, hopefully recovery, it is quite striking to see how little of that actually sits within a Spec Comm, right? And medicines in particular are only one part of that spectrum, but for obvious reasons many of us get focused on the medicine or the product we're actually selling. And we miss the peripheral vision really of someone's spell as James is involved with oncology or we think about somebody with MS. That's a lifetime of services and care. But how much of it is really in that specialised box? That's important for us to understand what we're about to talk about in a minute. And not all Specialised Commissioning is specialised really. It's certainly not high cost and and low volume. Again, prostate cancer is an obvious example. As something which is actually high volume and sometimes low cost. If you dunno what a shelf or group trust is, then put it in a chat box or go into Google.'Cause it's important for you to know. The Shelford Group are the biggest trust in England, there's a dozen of them. But if you think of any tertiary trust or foundation trust, at least two-thirds of its income will come from Specialised Commissioning, okay? So this is really, really important. If in my case, Newcastle hospitals or looking at James there, the big hospital in Bristol, UHB in Birmingham, The Radcliffe, etc. Spec Comm is a huge part of those hospitals income, right? Next slide Lily, please. Let's just quickly go through the past system. So if Mohammed and James were the same age as me, but it was interesting, Mohammed straightaway mentioned about PCTs. When I worked here as a director in the PCT, this was my world. So because it's an insurance scheme, we used to work with the PCTs around us. So one of us led on mental health, one of us led on oncology, one led on children's services, one led on neurology. We were buying groups working as insurers if you like, and spreading things out across a big population. But each PCT had a Spec Comm budget. That was based upon our population numbers, our epidemiology and to be honest, historic outturns from the past. So the way that services have been constructed, high-cost drugs, HCDs, they sat within that budget. And interestingly, they weren't usually ring fenced. Mohammed and James might explain to us the importance of ring fencing later. But they were crucially managed to budget at a local level. That's why we created insurance schemes and shared those budgets across larger geographies. So phrases like post co-prescribing, the other side of that, its not a very nice term, Shroud-waving those kind of things were prevalent. And the way that services were conducted, access to services was extremely varied. In fact, I can remember times when you'd have a four bedded bay in a hospital and two patients might be on one medicine and one pathway and the other patients weren't. And that's because of the PCT that they were resident in. I can remember those days. Similarly, NICE implementation could be managed. Yeah, people like me working in PCTs used to find ways of implementing NICE in a managed way that made sense for us to manage the budget.'Cause that was the primary thing that drove our behavior. Okay, next build Lily, please. What we've had in the last few years, and I'm conscious for many of you, this is the NHS that you are familiar with. NHS England has led on Spec Comm. We've had CRGs, they set the national frameworks, a certain amount of consistency. NHS England has paid for the service delivery by providers like at James's trust or some of the trusts I've mentioned. The high-cost drugs are a pass through cost. And people like Mohammed have used Blue Tech to administer that and control that process. We've had exceptions around the CDF and some other conditions. They come from different roots. But non-specialised services, in other words, if I were somebody with prostate cancer or somebody with MS, the Specialised Commissioning aspects of my care were funded in one direction and by one body. But the rest of my care, which is often the majority of the things that happened to me, they were paid from outside that, previously by the CCGs, now by the ICB. So both of those boxes are gross simplifications really what's been happening. But there's some very important things about those.'Cause next slide please Lily.'Cause when we move to this, and this is one of the areas, I expect Mohammed and James to come back and say,"Well, hang on a minute, David, that's not quite how I see it." Over the summer, we've had in my view three key documents that came out. The first of these, let's call it the 'roadmap', that had quite a lot of attention in our world of market access, your world as the people who are listening to this call. There's quite a lot of awareness of this and a lot of war gaming analysis. It contained crucial annexes that identified medicines that would be treated in three different categories. Then we got the middle one. Let's call that the 'agreement'. This is far lesser known. And tended to have internal NHS discussion. But it introduced a crucial aspect because that agreement set up the contractual system within the NHS for ICBs to work in collaboration with each other, to act as insurance schemes, to act as Specialised Commissioners in a devolved sense. And then the third one is when I'd be surprised if many people here are seen, and that's the cash flow standing operating procedure. Let's call that the 'SOP'. So when we get off the PowerPoint and let's get into the discussion, Mohammed and James might refer to the 'roadmap', the 'agreement' or the 'SOP'. Perhaps they're also going to mention other documents. Next slide please, Lily. Now those three documents are pretty extensive, yeah. And full of arcane technical NHS language. And someone like me who's made a living from interpreting them. I've really struggled. I've gone back and I print them off. I'm not joking, I hold them up to the light sometimes to try and read between the lines. They really need a lot of work to interpret. But what I've got on here are 10 consistent elements that I believe are present. Either as facts or as raising questions. Let's go through these carefully, because each of these is really impactful for you. Now whether you work in pharma, whether you work in devices, diagnostics, or you supply services, these are really crucial to us. So the first one is they all consistently point to some level of delegation of Spec Comm coming to ICBs. The debate has been when? So some of those documents, in fact all three suggest that it would be as early as April, 2023. Yeah, in five months time, four, five months time. But as you'll be aware, there's lots of rumours and policy advice around that really will be in preparation and we'll hit the ground running from April 24. So that's probably one of the first things we want to establish from Mohammed and James. When will that delegation happen? There is definitely in all three documents exceptions, they're talking about ultra-specialised services. The first one the roadmap says, if there are fewer than 500 patients in England in a year with a condition that will almost certainly stay nationally commissioned, okay? There are statements that say the CDF will continue to be the CDF. NHS England retains NICE and CRG roles, they're referred to. All of them suggest that some ICBs will work in collaborating groups if they're too small to absorb the risk. Now I'm talking to you from the biggest ICB of all, the North East and North Cambria, there's some things I can share with you today and there's some I can't, I'm on all kinds of ICB working groups. But what I can share with you is my great big ICB, which is over 3 million population. It is still the intention to have as many services possible devolved as soon as possible, within the rules, okay? That's the intention. Now, whether that's possible or whether that's desirable, that's a different question. The roadmap in particular talked about the suitability and readiness test. In other words, is an ICB big enough? Is it financially sound enough? Is it mature enough? Is it in patients' and clinical services' interests for James there in Gloucestershire, which is quite a small ICB as an example. For them to go it alone or for them to go in collaboration. And if so, which specialisms? There is an element here really important of the transfer of risk to local level. And a lot of that is because of the next two or three really critical issues.

The first one is:

all those documents reiterate that the Spec Comm budgets in the future, according to the policy that asserts written, will be population-based. What that means is, potentially, Mohammed's working in an area in Frimley, which is relatively affluent. I work in an ICB, which is relatively socially deprived. We are funded per head at a much higher level than Mohammed's ICB. That's what a population-based budget suggests. So different per capita budgets according to the ICB. One of the biggest aspects of risks that scares people out in the NHS, is there's no real detail in any of those documents on how the baseline budgets will be constructed. So if I'm Mohammed's equivalent in Gloucestershire working with James or the director of finance or the chief officer of the ICB, do we know how much money we're going to get for Spec Comm? Or for neurology or for peds or for breast cancer? None of that appears to be clear. And why that gets really interesting is the roadmap in particular, well, none of the documents talk about what the NHS calls ring fencing, which is preserving money within a certain dedicated budget. But it also makes suggestions that encourage virement. And my ICB, I have to say rightly or wrongly, is very keen on this, what does that mean? It means, let's imagine a... We'll take an example, let's go back to neurology, yeah? MS, RA, Parkinson's disease, the Specialised Commissioning aspects of that. Let's just say for the sake of argument that a hundred million pounds is devolved to my ICB. That contains all the goods and services, all the medicines, all the nursing, all the doctors, the whole shebang of what it takes to care for patients with those conditions in Spec Comm. So potentially locally we could say, of that a hundred million, 20 million is spent on drugs. Let's take that down to 17 million. We'll take 3 million and we're going to put that in better prevention. We're going to put that in diagnostics. We're going to buy specialist nurses. We're going to buy some new scanners. That's virement. The roadmap, the first of those documents, teases by suggesting that is a real benefit of devolution, that ICBs will be able to look at the basket of funding and spread that in ways that makes sense to them locally. Okay. So next slide please. Right, the good news is, that's enough for me. Lily, if we can close down the slides. And apologies if I went through those a bit slowly, but I did it deliberately so we don't have to return to them. So the first thing I'm going to do with Mohammed and James Mohammed first, is say, does that make sense to you? What aspects of that do you disagree with? What would you add? If you'd produced those slides, what kind of things would you have been putting in? So Mohammed first and then we'll come to James. Mohammed, what's your perspective?- Thanks David. That was a really, really useful summary of the situation as it is. I think one of the things that I might just throw into the mix there is whilst not disagreeing with anything that you've said, would just be about one of the other potential benefits which might upset James and his compatriots in one of these large tertiary centers. But also in terms of access for patients, if Spec Comm is delegated, whilst the CRG will still be setting the national standards that need to be met, there is the potential for local ICBs to identify delivery closer to the patient for some of these services, which is potentially a financial threat to some of these large tertiary centers. As you said, if so much of their income comes from these Specialised services, and in contrast to the historical arrangements where the funding went to the provider of services, in theory in future the funding will follow the patient. So if that patient's not going into the hospital in Bristol or the hospital in Birmingham where they're going down the road to Solihul or down the road to the outskirts of Bristol instead and receiving a service there, that is potentially a disruptive risk to those large providers which is one of the reasons why depending on who you speak to, they have different views about Spec Comm delegation and whether it's a good or a bad thing. I personally see it as a real opportunity to improve delivery of services. You've outlined there the possibility of, and really the rationale why this makes a lot of sense. The fact that Spec Comm was never in isolation. The patient would go and access a variety of other services before they landed in the Specialised Commissioned service, and also they would exit that Specialised Commission service hopefully at some point. So it makes sense for that holistic look. How do we manage the care of these patients right through the journey before they enter Specialised Commissioning and out the other side. And if there's things we can improve beforehand to perhaps have few of them landing in that Specialised service, that was something that was always in the gift of those Commissioning those other local services. And having that split with NHS England kind of disincentivised that holistic view being taken, it was kind of like, actually that's NHS England. They sort those ones out so we don't need to worry about them. Whereas if you have that devolution down to the local system and you say, "Well actually it's all your money now." And then there's that incentive to say,"Well actually, if we could manage these patients better earlier and end up spending less on them in that Specialised pathway, isn't that a good thing? And shouldn't we be doing it?" So I think that would be one of the things I would add is that risk for existing providers if things are going to be changing too much.- So just to summarize that Mohammed, and I can see now why you were approached by the ICB, It's good news for you and your colleagues in Frimley. Possibly for me, if I was a Frimley resident with MS or whatever, we can use examples like that with hemophilia, but there's a threat in there to your hospital compatriot sitting in a big London teaching hospital on the fringes of Southwest London, yeah?- There is, I mean-- (indistinct) somewhere yeah.- That's been a tension right since the inception of NHSE in actual fact. When NHS England arrived on the scene and replaced the PCTs, there was a whole raft of services, which they said,"Right, you are a DGH, you can't deliver these any longer. These need to be delivered from a tertiary center." And you mentioned MS. I remember having conversation saying,"Well we've been managing MS for the past 20 years and I've got 270 patients that we managed. Where do you want me to refer them to?" And then as a consequence of that, there was a recognition that actually no tertiary center could absorb 270 patients from our DGH. We were one of the few DGHs that managed to hold onto a Specialised service compared to others. Now, I'm not expecting it to be a case of there being lots of services that will suddenly get devolved down to local trusts, but I think there will be a fair few either where there's existing shared care arrangements in place or where there's historical experience of having delivered those services in the past pre NHS England where you may feel that there's some appetite within the clinical community to say that actually why are we sending our patients 50 miles up the road when we've got the skills and competence? And what we need to do is have our local service demonstrate it meets that national standard set by the CRG. So there's an opportunity if you're an optimist at delivering care closer to the patient, which I think would be beneficial. But at the same time, there's a lot of potential for disruption from that. And depending on who you talk to and when you talk to them, they'll kind of say to you,"Oh, no, no, no, this delegation isn't about that at all. It's about local systems acting as the assurers for NHS England. And that opens up the conversation, well what exactly does delegation mean?'cause delegation in my mind means that actually you are empowering me to change things. If you're simply saying,"Here's the money, but we're not going to allow you to change anything." That's not really delegation, is it?- Yeah, and Mohammed, can I just go in quickly before I come to James because I bet there's people out there now saying,"Yeah, but what I want to know is when?" For the first question is, when do you think there will be some kind of delegation? And then we can get into what delegation means, but is it '23, is it '24 or is it never? What is it?- I'm was very relieved when I had a meeting with NHS England and the timeline had shifted'cause I was expecting there to be a mad frantic a bunch of activity between now and March next year. But that timeline has very firmly been pushed back. And I would anticipate we're not going to see anything before 2024. We will see some path finding and some pilot work done, I think in certain localities. I think both ourselves and our neighbors in Surrey Heartlands have had a conversation with NHS England about possibly being pathfinder sites for some delegation work.'Cause yeah, within the southeast region, when the readiness assessments were undertaken, none of the ICBs indicated that they were ready or had the appetite to take on delegation. I think that became clear fairly early on and that's where the timelines shifted. So there'll be a whole bunch of work undertaken in 2023. I mean some of that is they'll be setting up the reference group for Spec Comm in the region. There will also be a, I'm sorry, I did have it. Yeah, a Spec Comm delegation reference group is planned to be set up as well as a Commissioning committee is planned to be set up. And those will really inform how we navigate that journey into 2024 about landing the delegation piece. There are some particularly cynical individuals if you speak to them who'll say,"Well actually we know what's going to happen come 2024, there won't be sufficient progress made and it will end up being pushed back again." I'm optimistic that that won't be the case. I'm sure we will start seeing some delegation happen in 2024. But as to the original roadmap, which suggested 60 odd services in March of next year and the remaining sort of 80 to 90 odd. Well I think there was 30 that would remain with the NHS England but the others ones would be over the course of the next year. I think that timeline was very ambitious and didn't really factor in the amount of other pressures the NHS is dealing with currently.- Well, thank you, Mohammed. I'm going to come to James now. Now you've been very patiently right now. But Mohammed, it's great, I'm going to highlight. You said, "Depends who you talk to." I'm 300 miles north of you, I totally agree with that. I think your analysis is right. Everything I'm hearing 2024 is the real goal. But something else you raised there, which again, our audience will be intrigued by'cause where is this written down really. Is this invitation for some people to go as some kind of innovator or some kind of pathfinder. I contributed to an ICB draft document this week and I was only supposed to add a paragraph, but I read the whole document. And there were paragraphs in there, exactly the same thing, responding to invitations to become some kind of accelerated partial site earlier on. And I've found that extraordinary. I've never seen that written down and there it was in a document. James, I know you're a bright guy I'm going to put a really broad question to you. Say whatever you want, you've listened to me very patiently, you've listened to Mohammed. What's on your mind? What's the first thing that come to your head on this?- Well, I was just looking up when the latest that the UK can have a general election'cause it's January, 2025.(both laughing) The cynicism in me would say that as Mohammed said, whether it'll even get too far and then it'll have to be thrown out, who knows? In broad speaking, I totally agree. I really enjoyed your slides, Dave, especially about what the PCT old days and the current, and looking at where it potentially could go. And I agree with Mohammed around the opportunities and the risks. For Gloucestershire it's really interesting because actually we are not a tertiary site. And actually if we got... It's an opportunity actually where you've got Bristol and you've got Birmingham above us, but a huge population in between. And obviously got Swindon to the side as well and Oxford up to the North.- Yeah, James, we've lost you. We'll come to Mohammed. Mohammed, I'm already keeping an eye on the time, so I'm going to ask you questions that I think our audience will be itching to ask. Who decides what medicine? And if this does roll forward in the future, in the way that you described? If I live in Frimley, who decides what medicine I have?- Well, in theory that will still be NHS England deciding that 'cause the CRGs will set the standards. So effectively from the discussions I've been party to what's actually commissioned, it still remains with NHS England. How it's commissioned is where the local flavor has an opportunity to perhaps differ from place to place. So you might have one particular ICB where that may be being commissioned, where it's all going into one tertiary site. Whereas another ICB could say, well actually we will have a hub and spoke model and we'll have maybe the initial appointment at the tertiary site and then all the ongoing management will be much more local. But in terms of what the standards are for that service, those will remain defined by NHS England through the CRGs. And equally coming back to that point about the historical postcode lottery we used to have. There won't be any opportunity for any local ICB to decommission a Specialised service. So it's not going to be sort of delegated in that manner, whether you've got entire freedom to say,"Well actually we've been given this money and now we're going to do what we like with it and we're not going to spend any of it on in the area that it was actually given to us for. So yeah, I think the decision making on this, and this will be interesting to see how these committees that I've heard of this Joint Commissioning committee, how that will function. There seem to be a lot of new committees or repurposed committees being set up at a regional level. I think, without wanting to get off topic, we're hearing about these new priorities committees in common. We're having discussions in the southeast about a new priorities committee that will cover the whole of the southeast to replace the existing historical ones. So there's certain things which we're expecting to be done once sort of higher regional level. And then implementation happens at a local level. That's kind of the picture that I'm seeing being painted of how these things will work in future. And Spec Comm I think will be that. Again, because it's going to be at a national level effectively in England It will still sit with an NHSE and that's to the decision making of what is commissioned and what isn't.- But even just small little marginal changes because, going back to your optimist. Hi James, thanks for coming back to us. So, well what Mohammed was just saying there was I asked him about if I were a patient who decides my medicine and he was saying about the importance of CRGs remaining, but then mentioned about in the southeast where he is, there's new committees in common being established looking at priorities. So if I was in the audience, Mohammed and speaking for our colleagues who are, I'd still be thinking, well, hang on on a minute, you're saying there's not going to be major changes, but if patients move in your case from being at George's or Wexham Park or whatever and come to you, there is going to be a change. And if you just make marginal changes, if a little bit more is diagnosis or a certain doctor has a certain view about the ranking or something like biosimilars coming back to you, I mean James, how much change do you expect to see in reality? Will it be normal state and it's just a Gloucestershire stamp on it? Or would you expect to see some change?- Well, I think the fact is we've talked a lot about the fact that there's so much uncertainty. If there's so much uncertainty, I don't see a huge amount that's going to change in the near future. I do think if we have a localized approach like we will do, or sorry, it's proposed, my concerns are around the experience I've had with NHS and in the past around pathways. So a lot of pathways aren't necessarily all in the ICB footprint. They go across a number of different ICBs. And this is what potentially people don't necessarily understand. When a patient goes into the NHS, they don't suddenly go,"Oh, I'm in a Spec Comm service, or oh, I'm in a CCG commissioned service." It's one in the same thing. If you take one element of that out, you put other things at risk. Example, if you said upper GI surgery goes to X hospital, that has a major impact on your general surgery. So you are going to rip out a service and potentially if you're going to continue with lower GI surgery, for example there, why would someone go here to that hospital which has just had that service ripped out. And all of the other support services that go along with that. So you can look at the cancer side of thing, for example, cancer pathways. But they're the same surgeons that will be doing the routine work. So they are one and the same thing. So you can't see this as an isolated thing in the sense of the service provided, but also within your ICB. Now David, like in your area it's so big that a lot of the pathways I imagine are held within that area. But for Gloucestershire, it's very small. So we do, do a lot of our own treatments, but there are services pathways that go north and south. Who's to say that the decisions made in Bristol won't hugely impact on us and the services that we provide. And what I'm saying-- Are those conversations, and again, in the confidentiality segment not saying you're a critic of anything. But are those happening because as soon as you said that, I was thinking about things like small children who will have multiple Specialised issues, unfortunately. Or you say it's very rare that somebody says,"I've just got 'a certain kind of cancer'. You've probably got a whole series of other things. Are there groups looking at this? How do we ensure that the wheels don't fall off?- There are groups. So for instance, for peds, yes, but I don't get a sense that it's much evolved than the actual network system that would be set up to ensure that the pathways are operating in the right way. I'm not close enough to it myself, but I don't get a sense that there's huge conversations that been had around provider collaboratives or how Pathways would look in the future for me on the ground very much. You can only just look on BBC news and look through the news articles around the NHS to understand where senior leaders views are looking. And it's very much on that urgent care space and the finances. Obviously all ICBs need to not have a deficit by the end of the financial year. That's going to be very difficult for virtually every single ICB. So that's one of the major focuses. And obviously as I said, urgent care is the only game in town really in a lots of ways and keeping patients safe. You can just see the news around UHB Birmingham today. So for me, I think that the climate its not being particularly easy to look at that strategy and looking forward to what's going on. And obviously NHS England and NHSI merging in the last year certainly hasn't helped with that either. There's huge, huge transformation that's gone on behind the scenes that no one really would know unless you work with people in NHS England and they say,"Not sure if I've got a job next week or I don't how it's looking." And you think if you're looking that way and thinking about if you've got a job next week, you're not going to be thinking about that one, two years ahead of you.- Yeah, I'm always the oldest person on these calls. And I say I've never known times like it, the disrupted nature of the change, the poor change management, the poor comms the basic things that are so important that seem to be neglected at the moment. Again, I'm keeping an eye on the time and I wrote down some basic questions, not basic, fundamental questions I want our audience to have today. You've both alluded to how difficult it is, it's striking James, you're saying,"Well I keep an eye on the national news to try and understand what's going on." For our friends out there who work in pharma and devices and diagnostics, what's your advice to them? Where should they go to try and get on top of this change? Or at best to be a step ahead of it? Mohammed where would you... Are their sources people can go to? How can they try and find out what on earth is going on and modeling it?- David you set me up nicely for a little anecdote. I had a conversation with a colleague from pharma and it was an advanced budgetary notification meeting. But within that context they said,"Oh, what's happening with Specialised Commissioning devolution?" Or delegation rather? And I looked at them and I said,"I don't know, you tell me." And they laughed and they said,"Surely if you guys dunno what's happening with that in Frimley, what chance have we got outside the system?" So I mean I think that these types of webinars, these sorts of forums and discussions are very useful to be linked into and tap into. There's the NHS Futures platform, which I'm not sure if that's actually accessible to people outside of the NHS. I'll confess ignorance'cause I find that platform so bloody difficult to navigate that I don't even bother trying any longer.- I don't think it's directly, but I don't think it's too much problem. And I'm not saying anything untoward. If I worked for a big company and I had a good relationship with you, you're allowed to say,"Oh, you've seen this or I'll print it off for you." I don't think there's anything on there which is meant to be strictly confidential is there. But as you say, it's hardly the most user-friendly. It's not as if you could put Spec Comm Clinical Hematology in or something like that and the answer comes out. Is it you're both shaking your head straight away. Sorry, Mohammed, James, what about you? Where would you go if you were an account manager for a big device company or a medicines company? How on earth do you get on top of this?- It's really tricky, isn't it? I suppose obviously they are regional. The NHS and regional bodies are still around certainly for cancer. There is a regional guy still working with us, so they're all in post. So from my point of view, if you've got an in within the NHS England, it's asking about, there will be still people overseeing some of this. NHS England haven't, by the fact that these documents have come out, suddenly just dropped everything it's still the status quo. So from my point of view, if you can get an in within NHS England obviously that's a given within ICBs, I'd be looking at someone, either the overseas clinical programme groups or Clinical Reference Groups within the ICBs, they would potentially have an understanding because they would have more of a strategic view across quite a lot of work that goes on within those ICBs. And there's also obviously there will be a Specialised Commissioning link within ICBs. But it's getting the person obviously you could potentially FOI the ICB to get a name of someone and so having a carefully constructed question would elicit an answer. So that is one way of doing it. That would be my advice.- And your senior medics, they're often the key opinion leaders, the main people that are friends here on the call. How aware are they of the sort of things we're talking about today?- Not much. Well the cancer drugs fund for example, I talked to my oncologist lead who's very, very sharp and he was just sort of like,"I'll believe when I see it." Is essentially his response. But he wouldn't really care if I'm honest in a lot of ways, as long as he can continue the way that they would work. I mean, sorry, that's probably a disservice. He does care'cause he's looking from a strategic point of view, but as long as he can continue how they're delivering, he would be looking at it more from an opportunity of whether there's any more additional funding. But I wouldn't say that there was more additional funding coming from this. I would actually say that you're in competition with more services. And actually some of this money being top sliced and put on the bottom line of ICBs. But that's my, again, a slightly cynical point of view.- No, it is a realistic one. Mohammed, you were shaking your head, how aware clinicians and by commissions I'd also extend that of course to you and your peers. Is this something you talk about all the time? You on top of it.- Well, I would say that for myself and my peers we're aware of it because we were meant to be preparing for it but we're aware of it in (indistinct) as much has been shared today. I've got some other slides and of the presentations that have been shared with me that flesh things out a bit more about work we might be doing collaboratively in the course of 2024 to try and land this. In terms of clinicians though, I think many of our quite senior clinicians, they've been so bogged down this past year with the service pressures, they haven't really had a chance to take a step back and have a look at what's happening in the strategic environment around them. Even in terms of the establishment of the ICBs, our local DTC chair, it kind of came as news to him about the ICBs and I was asked to do a presentation about what the ICB was and what it actually meant.'Cause in their mind it was,"Oh that's just a new name for the CCG, isn't it?" And I kind of said to them,"Well no, if it's the new name for the CCG, then something is gone seriously wrong'cause that's completely not meant to be what the ICBs meant to be. It's meant be much bigger than what the CCG did. Bringing things together with local authorities, with social care and looking much more holistically at population health." It was interesting, David, your anecdote at the start about when you were in the PCT world and you would come up with ways to effectively manage NICE implementation that didn't blow the budget. And then I think I remember those conversations in the past when you'd have therapies and say,"But it's going to save this much in rehab costs or this much in long-term care costs." And the conversation was, yeah, but we're not responsible for that budget. So we can't really agree to fund this even though it would save money elsewhere. Now when you're looking at a much more systemic view, that's where I see the positive benefits of the ICB world and the potential for bringing this all into one pot of money with one group responsible for it. But yeah, I would say that the awareness in the clinical community certainly within my local trust, it is quite low at the moment.- So let me ask you so that... Who's in charge of it? There you are, Frimley, you're the highest ranked ICB in the country. Who's in charge of making sure that Specialised Commissioning is devolved and implemented according to the policy in the best way? Is somebody in charge of it?- There is somebody in charge of it.'Cause I remember posing the question'cause I was told with this readiness assessment that had been sent out for ICBs to respond to. And I remember thinking, okay, I wonder who that's gone to. And I did get the name, I'm not going to share their name here, but they are tasked with various work programs. But in amongst that was this delegation of Specialised Commissioning. And I mean the one thing that we haven't touched on particularly, but it's also been flagged as being something that was going to be delegated was the delegation of POD delegation. So pharmacy, optometry and dentistry in primary care. That was again, something which was commissioned by NHS England which was going to be coming down to local ICB level. And that again I wouldn't say has hit the buffers, but it's been slowed. And what we are gathering now is that, it's going to be probably a case of you'll have piecemeal delegation of those services and you might have one ICB that decides that,"Okay, we're going to deal with dentistry." Another ICB might say,"Okay, we'll do optometry." And another ICB might say,"Well we'll do pharmacy." So you're not going to have this sudden big bang of right, here's all the POD contracts all delegated down to ICB level. So I think there's a slowing, shall I say, of the movement along the track, but the direction of travel is very clear and ICB-- That's a great way of summarizing it. James you're in a good concerted ICB where people know each other quite well and I've got long working relationships. Who do you know is, don't mention the name if you do, what kind of person or is anyone in charge of all of this? Is anybody collating it on behalf of one Gloucestershire?- I don't know the name. I know there is someone looking at it, but I think from it pretty much summarizes exactly where Mohammed is, is that I think they're still in very early days of understanding what actually that means and what it means for them. So I'm not privy to it, but definitely think it's certainly not evolved. Certainly not.- Okay. Now Mohammed's obviously had to go out there. Oh, he's come back. It gives me a chance though Mohammed, firstly to say I'm so far north of you. I can't believe it's still daylight where you are, it's dark where I am. The second thing I was going to say is, James you've obviously got specific, you mentioned the CDF, yeah? Now there'd be colleagues if you could try and be brief, I know it's a complex topic. Where are cancer services going? Where are the cancer alliances going? CDF, you said there about your clinical colleagues saying, there's too much going on. Where do you think will be in a year's time about cancer services and the CDF and particularly the medicines around it? It's such a huge topic.- I don't think we'll be any further forward if I'm honest. I think we'll be remaining status quo. I don't think, certainly the alliances aren't looking at anything around, evolving pathways in that transformational space of centralizing them in at etal. There isn't the capacity or the appetite Cancer Drugs Fund's interesting when you just look at some of the information there's that sort of suggestion around devolving that to regions/ICBs. But I can't see that happening now certainly with the amounts of uncertainty and transformation that's required before that. I could see that being quite a high risk to go with Cancer Drugs Fund as a first thing to look at.- Yeah, politically it be-- Politically.- Mohammed you would not(indistinct) obviously, you agree, yeah?- Yeah I would say that's probably going to be the one that's going to be the lowest down the list of topics that would there would be an appetite for from ICBs. I think that would be seen as one of the highest risk areas that they're probably going to say no, actually we'll leave that on the to-do list as it were.- So, okay, that's great'cause that gives me the... If we just do this as the last question, it'd be great, but I've got a couple more I'm going to ask you. So try and give me quick answers. And that is, if the CDF is in the, let's leave it, that's too hot to handle, what do you think will get addressed first? What would be on the top list then Mohammed, and I'll come to James.- I mean I think it's going to vary between ICB depending on the level of expertise you've got locally and the appetite there is around this for different areas. I mean I think for ourselves we might be interested in some of the pediatric Specialised work and in fact the only difference is the fact that the age group of the patients, the actual treatments, etc, are largely aligned with what's offered for the TAs for adults anyway. So that to my mind and we'll have existing shared care arrangements with tertiary centers anyway. So that to me seems like a fairly easy one or the low hanging fruit to use a cliche that could be relatively quickly delegated down to local level. Other than that, I mean I think depending, as I said on what the clinical expertise is, I think there may be some appetite for some of the Specialised rheumatology or Specialised dermatology to be done at a local level. And again, that is due to the historical practice where that was delivered locally in the past anyway.- Yeah, I think that's really interesting. As I said, I'm 300 miles north of you, I read this mysterious document earlier this week and when I read the paragraphs that perhaps I wasn't supposed to read the two big things that were in there, dermatology and rheumatology, okay? It actually led me you put in a little comments box I've got why dermatology, I'm still waiting for an answer. But dermatology and rheumatology, yeah. That has my ICBs big things. James, I mean, what do you think people are going for where would you see a change?- Well, so it sounds like I'm sucking up to you, David, but I think I would've said exactly the same of looking at some high volume sites, especially with elective recovery being such a big thing. Dermatology, I know why they're looking at it, it's because there's going to be some quite significant routine backlogs there. Dermatology in terms of dermatologists is an area clearly that we have workforce issues in that particular area. So I would suggest they'll be looking at certain services that are impacted, especially around DGH's with high quite specialist services. So they struggle for workforce and paying absolute fortunes for locums. I can name a number of specialties that are like that where you would want to centralize those and look at those pathways and get your throughput much higher and get your efficiencies. So I think sites which have a lower complexity, higher throughput is definitely where I would be focusing. That's not necessarily what they will do, but that's certainly what I would be doing.- Okay, we've got a few minutes left, so in those few minutes, let's try and imagine ourselves out in the audience, yeah. And working with the companies they work for. Just on everything that we've said over the last 50 minutes or so. But just in your last answer, James, I was thinking if I was out there I'd be thinking, what does centralization mean to me? Which hospital's going to lead? We've mentioned about collaboratives. Mohammed is talking about, forgive me, Mohammed, summarizing it, but activity possibly coming out of London, being repatriated to Surrey and Kent and new services being created. But similarly, not too much change and not too much change on forumlaries and things like that. So for each of you, if you were out there today and working in one of these big companies or a small very focused company, what's your advice to them? Mohammed, what would you advise them to do? What should be on their list to take away from today's event?- I think that they need to build up their network outside of those traditional tertiary centers that they've been invested in. Because there's the possibility of some of those services coming out and them needing to build up relationships with other organizations. I mean, you mentioned it previously about some services coming out. We've done that locally with RMS 'cause we've taken that out of St. George's at the Frimley Park site, and we've taken that out of Charing Cross, our Wexham Park site. And at the time there was conversations with NHS England'cause they thought we were trying to poach activity and we said no, we've had the conversations with the tertiary centers, they're at capacity. They would love for us to take these patients from them. So we're not poaching, we're actually helping. So I can imagine those sorts of conversations being the easy ones where actually tertiary sites are quite keen to have some help with the capacity. I think the more difficult ones will be where tertiary sites feel that they're going to be impacted financially if they have any activity leaving them to do it more locally. But I think for that it's really having that awareness about where services might potentially shift. If you've got a tertiary center and it's at the center of a number of feeder DGHs, is there likely to be some shift in the other direction? As they start delegation.- Great advice. James, in 30 seconds, what would you advise people to do?- I couldn't get anything better than Mohammed its that term the phrase war gaming, have a look for Gloucestershire as a classic example, massive patch in between two tertiary that there's opportunities there to grab some more market share in the future. Tertiary centers are overrun. So where are the backlogs, where do they exist? And the data's there. It's all in the national forums.- Yeah, and I'm thinking again, I can see why you mentioned dermatology. You look at the case mix of a thousand dermatology patients and I wonder how many of them are really Specialized? And you want those to go to the tertiary center, don't you? You want those in front of the right doctors, but the other 600 patients, do they really, and they're on that waiting list and you could make a difference... It's that kind of, yeah. So let's leave on that optimistic note. I'd like to thank you both, particularly Mohammed. It's nice to see the sun shine now. I wouldn't like to live in Surrey or anywhere near it, but it's good to know you've got some sunshine there.(David laughs) I've read in the paper that you've got houses cost hundred thousand or more there. I couldn't possibly live there, but no seriously, it is starting to get dark where I'm already. James, thank you very much for your insights as ever. For everyone who've dialed in. Very complex topic. I'm sure there's also a lot of uncertainty you're left with, but at least now you know that there's uncertainty that people are right at the center of change still have. So if you are still confused about some aspects it's right to be confused. And they've given you some really good tips about where you can go to try and keep on top of that uncertainty. So thanks very, very much for everyone today. And see your goals soon, I hope, at another Mtech Access webinar. Bye-bye.- 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.