Pharma Market Access Insights - from Mtech Access

What's happening with specialised commissioning in the NHS?

• Mtech Access • Season 5 • Episode 10

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What’s happening with specialised commissioning in the NHS? How likely is a delay in delegation to integrated care boards (ICBs)? How and what should Pharma and Medtech plan for amidst all this uncertainty?

Malcolm Qualie (former Medicines Lead for Specialised Services, NHS England) speaks to David Thorne (Principal Associate, Mtech Access) to explore specialised commissioning in the NHS and what to expect as we head into 2024.

Malcolm Qualie and David Thorne explored:

  • Specialised commissioning in the NHS
  • The risks and opportunities that devolution to ICBs will bring
  • What we can expect to see in the short and longer term
  • How industry can support ICB leaders through this transition
  • How Pharma, Medtech, and Diagnostics companies, whose products come under specialised commissioning, can manage these risks and uncertainties


Learn more at https://mtechaccess.co.uk/nhs-specialised-commissioning/

This episode first broadcast as a live webinar in Decmeber 2023. 

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- [Narrator] 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 med tech 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 everyone, and welcome to the highly anticipated Mtech Access Specialised Commissioning Webinar. I'm Jennie Smith, director of NHS Insight and Interactions at Mtech Access, and it's my pleasure to extend a warm welcome to our speakers for today and the participants who have joined us from all around the globe. For those that don't know us very well, Mtech Access is a specialist market access consultancy, and we provide strategy and solutions to help pharma and MedTech companies bring innovations and interventions to market both in the UK and globally. We also work as a collaborative partner with the NHS and these webinars, we invite speakers from our connections across the NHS to share their insights on the key topics of the day. Today we have two speakers, David Thorne and Malcolm Qualie, who are experts in their field, to share their wealth of knowledge and experience in specialised commissioning. Their insights are sure to be thought provoking and provide valuable perspectives that I think will benefit us all. I'm now going to hand over to David Thorne, who's going to facilitate this session for us, and he'll undertake a more formal introduction. It's over to you, David.- Jennie, thank you very much and thanks everyone for joining us. It's going to be quite a day. Our friends at Mtech Access could not have timed this better. As I'm sure some of you'll be aware, if you're not, you're in for some interesting surprises. Malcolm, I'm going to go straight over to you and allow you to do your introduction yourself of who you are, your role, your immediate previous roles, of course. And to do that briefly, then I'll introduce myself. I'm going to make some commentary and we're going to listen to Malcolm, but Malcolm, over to you.- Thanks, David. So, I'm actually retired from the NHS, but I used to work for NHS England as the medicines lead for specialised commissioning. And I was in NHS England right from the start of that shift of specialised commission from regional to a national footing. And I retired in February, 2022.- Yeah, so Malcolm's really well placed to give us an independent view and to cover the things that, in particular that I'm not good at doing. And most of what we're going to hear today will be Malcolm's content. For those who don't know me, I've worked in pharma market access and consultancy, but also in field based and head office roles. I'm a former nurse, I've been a chief exec and a commissioner in the NHS. The reason, oh, and I work part-time now as the director of a primary care network. And you might think, why have I got an interest in specialised commissioning? The reason is, I've been a specialised commissioner in the past, out in a regional capacity. I've retained an interest as we've gone forward with the legislation that's happened over the last couple of years and kept in touch with Malcolm because this is one of the most intriguing areas. At the risk of sounding facetious, the first thing I do in the morning, and I did this morning very early on, is give my dog a breakfast. And it's attempted to use that as the kind of theme to today.'Cause the next thing was I logged on and saw what happened yesterday. So for those who don't know, NHS England had a board meeting yesterday and one of the important announcements made at that board meeting was a clarification of the latest steps of policy on specialised commissioning. So I'm just going to take literally two minutes to describe some of those before we set up the questions to Malcolm. Where we were previously, this policy has been around for what, probably for 18 months now. And that the first real statement of policy for our friends in the audience which was possibly the first time that this came across their desks was May 22. When NHS England published a roadmap for the delegation of specialised commissioning from NHS England back out into ICBs. We've had all kinds of iterations of policy, some apparent inertia, some mixed communication coming from the centre, various announcements that have been leaked through board papers, most notably through the ICB in South Yorkshire. What that's culminated with is the NHS England board, PPS today And in headline, where we are, specialised commissioning will continue to be delegated. However, what we will now see on the 1st of April next year is 20 of the ICBs in three regions will go further faster. They will go through the pace that the roadmap initially set out. The other 22 ICBs in four regions will not. So their progress will be deferred until April 2025. What we will get into with our questions is all kinds of detailed known unknowns, uncertainties, various levels of interpretation. But I would urge you to go into the document from the NHS board paper, not necessarily read commentaries that are coming out interpreting it, but read the source material and in particular, to follow through the annexes when Malcolm speaks, he'll talk a lot about annex two or annex three. Annex two for example, covers the financial situation and the defaultment of budgets and specifically mentions high cost drugs and devices, which of course you were fascinated with for obvious reasons. Okay, so read the annexes, not just the top line document, but basically what we've got now, if this all goes ahead next April, is a dual system whereby some parts of the country will work, go further, faster than others. And that is extremely intriguing as we go forward. So Malcolm, I've tried to be brief there. What is you, you've known me well enough to absolutely contradict what I'm saying. We can make this a lively debate, we can disagree. That's part of what people are dialling in for. In general terms, where are we heading and overall, what are the implications for our friends who are on the call today?- To be honest, I really don't know. I mean, I would agree with David. Please go to the website and I'm sure Mtech Access can send you the link if you struggle to find it.'Cause the NHS England website isn't always easiest to get around. But from 2024/25, there'll be some ICBs that will act singly to manage the 59 services that were identified to move across. Some ICBs will work in collaboration with the full budget for specialised services. Working through those services and delivering those 59 services. Some of those ICBs will have what's called a ring fence budget for specialised services, which means they can't move that budget out of specialised services, at least in 2024/25. So they'll have control of the budget, but they can't do anything with it other than fund specialised services. And then there'll be the others that don't have the budget at all and will continue to operate as they have done this year under this sort of joint working arrangement with the specialised services hubs. And then topping all of that off is the fact that whilst the budgets have been allocated on a population basis, actually they're using historical outturn for the budgets currently, which is based on, for specialised services, Trust-based budgets. In other words, the budget sat with the hub where the Trust sat with the point about population-based budgets, which I'm sure most of you know, is that the budgets sit with the commissioner to which the patient belongs to. And what they've said is, there'll be a convergence of these budgets over time not specified. So it could take one year, it could take five years, it could take 10 years to get to that proper allocation.'cause of course they don't want Trusts to fall over'cause they've suddenly had a shed load of money taken away from them because the budgets have been shifted around the country. And there's actually a table in annex two that shows you how far some of these ICBs are off their targeted population budget. So I mean, our colleagues online will be wanting to know what it means for them. And perhaps I'll just stop there at the moment for David to ask some more searching questions of me.- Yeah.- But I think it's watch this space.- That's a really good introduction and believe me, if you're out there thinking, hang on a minute, why aren't these guys coming on and giving us a couple of PowerPoint slides that succinctly summarise things. I promise you, this is a really complex thing in terms of what it says and then how you game it through. So what I'm going to try and do with Malcolm, if you take his excellent kind of exposition here, is to unpick various elements of it. Yeah, the high cost drugs and devices, the funding, the variation, what we might see, the kind of behaviours, what that means for you as companies. What that means for pharmacists who are still out there working in big Trusts and in commissioning organisations. The first thing we'll do factually, just so that we're not seeing to tease you, the three regions that are going for it on April 24, in other words, three months from now, so they are the east of England, the Midlands, and the North West. And I'm supposed to make a living out of this kind of thing. I wouldn't have guessed those three regions going to be the regions that would go earliest first. It's very, very interesting. Back in October there was something called a moderation panel met and scored basically the ICBs and their level of maturity, of being able to take on these services. Okay, some very interesting results are covered in quite a public transparent way in the documents that we referred to. So the three regions that are going earliest, east of England, Midlands, North West. So if you're south of that or like me, to the east and north of that, you will not be covered by this until the following year. So let's do this population based budget thing first, Malcolm.'cause that's the sort of thing that I think within the NHS people will focus on first. So they're saying they're creating a formula or they created one which is similar to the one that is used currently for secondary care. And that generally comes out with the result that the areas that have lower socioeconomic status, like Merseyside or Tyneside, the former coalfields, they come out the highest. So they seem to be suggesting, have they got that formula worked, have they distributed the budgets? Because they also say that the budgets will be published when the operating plan is published, which is normally black-eyed Friday this year that'll be the 22nd of December. So they're saying there's a commitment to actually publish the budgets then. But do you think they've worked out the formula and done the maths and what does it actually mean? Does it mean as I've just said, that the areas that tend to be poorer, to put it bluntly, are the areas that will have a larger per capita budget?- Well they have worked it out on a needs base, which translates into population based requirements for the money need for their particular population. And they've been working on this for probably some years, you know, even before it was announced that this was going to happen to specialised commissioning. And you know, as I said, this shift of the moneys from A to B won't happen overnight because they can't afford to let, particularly the larger Trusts'cause they will make a lot of noise that they can't just do that. So this'll be a transition over a number of years. The other thing is actually for drugs and devices, the high cost drugs and devices, these budgets are still going to be managed centrally. So although there's an allocation of the budget on this needs-based population-based system, the budgets are still going to be managed centrally. Now, you know, we've heard I think from some financial directors that they got the money in their bank balance now, but I don't think there's much they can do with it. What they can do though is the budgets they're receiving for the services. And I think when the original roadmap was published, it was about 13 million, 13 billion, sorry, for the 59 that we're shifting. So apart from those ICBs that are ring-fenced, the idea would be, and I know people out there will be saying, well why are we doing this anyway? Why are we trying to fix something that seemed to be working quite well with this managed central budgets for specialised services is there's a view that if you can invest further down upstream in other services, then some of the specialised services that are required now, might at some point go away. So a good example of that is having good obesity services so people don't end up needing bariatric surgery, which spec com, although we moved that or they don't need renal transplants because they're managing renal injuries better or they don't need chemotherapy because they're diagnosing patients earlier and surgical interventions will sort that particular cancer out. So that's the fundamental principle of why they're doing this. And also, you know, there's a mention of some pathways were broken and there wasn't a join up of the pathway for particular patients. So that's why they're doing it. They say these budgets that have been allocated are not the final budget. So when these budgets are published on what you call Christmas Eve. Then these aren't going to be the budgets that you're going to see in maybe two, three, four years time because they're going to, you know, squeeze in certain places, they're going to expand in others. And there's certainly in annex two, a mention of the fact around the high cost drugs and devices that they're mindful that obviously the tertiary centres use a a lot more high cost medicines than a district general does. And so it wouldn't make any sense to allocate to an ICB even based on their population, a budget commensurate with that area if a lot of their patients are having to go out of the ICB to get to that particular specialty service. The other thing to note of course is that it's 59 services and the totality of spec com is around about 143 services and the the remaining services, a lot of them are highly specialised, which is going to remain central, come what may, there's going to be decision made before 2024/25 about whether the remaining services, I think it was about 29, something like that, 28 or maybe it was 36. Anyway, they will either move to the ICBs as was the plan or actually they'll remain as a centralised funded service.- There's definitely a cohort of services that they're making a decision on. And just to go back, One of the beauties of Malcolm and I being sort of detached or semi-detached from the mainstream NHS and I guess also our age, is we speak very plainly and also pontificate a little bit. So let's try and do that directly.'Cause ring fencing is a really interesting thing and you and I, people won't be surprised we were chatting kind of this morning in preparation for this, really intriguing, we've now got some ring fencing, some ICBs will be ring-fenced, some won't. As you said, and I totally agree with you, one of the reasons they're doing this is to allow people to look at moving money across a pathway. How likely is that to happen? If you want to use a handy example like renal might be a good one, isn't it? If I was an ICB that's financially okay and the clinicians are happy that we would move money out the specialised services, move it upstream, as you said, in a better diagnostics or some kind of screening programme for diabetes or whatever it would be to affect our renal stuff or create local hubs for service provision. All all kinds of things that you imagine be doing. So firstly, could that happen? And secondly, let's be clear, could we take money out of the high cost drug budget and move it upstream? Or is it the service element of renal care? What could we actually do Malcolm?- Sure, well first of all, there's an expectation that that's what ICBs are going to do ultimately. That they're going to shift moneys and invest in upstream services in order to manage patients better and earlier. So that's an absolute expectation. And in fact, early on in this process, and you may recall, there was a letter went out to all the ICBs asking them to identify three pathways which involve specialised services to see how they could improve that pathway. And there was an edict underneath that, that whatever they did, one, it had to improve outcomes. Secondly, it had to improve equity of access and thirdly, it had to drive value. Now I think those three are quite difficult to get into one system in some senses because if you're going to invest in a pathway, it's going to cost money. I think the hope is that eventually it would drive value, but it might not have beginning, but you know, like I say, there's an absolute expectation that this money will at yeah, at some point be invested. Now those ICBs that have this ring fence money, I think that we can read between the lines and say, well last year you were overspend against budget and we don't want you top slicing the spec com budget to underpin your overspend in other areas. So you're going to have to work on that overspend that you've got for the non spec services that you already have. You know, you're not touching the spec company. Your other question about high cost drugs, well again, eventually you might see a shift of funding from some high cost medicines to fund some of the upstream services. But of course the turning round of the big oil tanker will take some time because you'll already have patients who've gone past the stage of, for instance, surgery being an option for their cancer'cause they've already metastasized, et cetera, et cetera. So, that sort of thing's going to take time. So you're still going to need those medicines at some point. And so yes, but not now. When, it's going to be years before I think they'd be able to touch the high cost medicines and devices' funding and hence the reason why I guess it's going to be still managed centrally. The other thing which is in the document, just as an aside, is that the moneys that have been allocated to the Cancer Drug Fund and the innovation fund haven't been allocated in that overall allocation. So, again, one assumes that they can't touch that money full stop because they haven't got that money. And that will of course create problems particularly for Trusts identifying uses of certain medicines within those funds. Some of which the indications will be in the EG cancer drug fund, some of which will be in routine funding, primarily with the ICBs. So there's lots of things to work out. But again, for colleagues on the line at the moment, I think the key thing is to sort of watch and wait and not panic too much.'Cause I don't think there's going to be a lot of changes around how the medicines budget is allocated for high cost medicines. How that is used and how NICE is implemented because again, and I'm going to stress this, NHS England will still be responsible for specialised commissioning and there'll be oversight of what the ICBs are doing. And they're going to have to fill in a 10 point questionnaire every year to demonstrate that they're meeting the national standards that NHS England follow. And that obviously includes, for instance, funding NICE guidance.- And let's get onto that. I am keeping an eye on the question box and I'm also going through really good pre-submitted questions as well. Okay, I promise we'll cover those. And Claire, I've seen your question, just to pick up on it, Claire, it's not three ICBs, it's three regions. So it covers 20 ICBs, 20 to 42. And also in your question, one of the things that's difficult for Malcolm and I is, what do you hear from us, although we've been around it probably 100 years between the two of us, is stumbling around, what do they mean by the difference of a budget being held, managed, controlled? Okay, what do those words mean? So Claire, it's interesting your question, you used the word oversee, that would be another question as you can hear from Malcolm saying, it's a horrible phrase. But what we're trying to do in your interest is war game through, what might be happening. So let's go on a central thing here. Okay, we're going over to a system now. I'm old enough to remember when we didn't have the current system that most of you would be used to. So over the last many years, we've had national specifications, NICE. We've had budgets that aren't population capitated because they're the, the drugs have been paid through in the pass through and the services too, okay, now we're clearly moving away from that. But in a very complex matrix where, for example, someone living in Huddersfield is in an ICB that is not part of the immediate devolution, but if they went to Manchester just across the Pennines from them, which would be in many cases their nearest tertiary centre, they're going into an ICB that is part of the devolution and to hospitals that are part of that devolution. So many of your questions, and I'm sure many of your ideas will be around postcode prescribing. Let's use that term. So this is something I've stumbled with Malcolm. If we have population based budgets, if we have varied approaches, how can we have consistency of NICE, I mean what, how do you think this is going to be worked through? And part of that question is trying to imagine, easy for you to do, I guess if you were an ICB chief pharmacist, how would you be responding to this? How are we going to achieve some kind of, it just seems like an impossible, it seems like a paradox here. We've got local variation, I can see why we're doing that. We've got national consistency. I can see why, how do those actually marry?(person laughing) You didn't write the policy.- It's all going to take time to bed in, that is for sure. And one of the things as a consequence of perhaps Trust-based funding where the funding was with the hub, so a London Trust, the funding was with the London hub. I think one of perhaps unintended consequences of that, which sounded like a very good system to have the budget sit and managed in the same place if you like. Whereas this person in Huddersfield who might need the service in Manchester isn't going to be sent there because it means the money's shifting away from their particular area. And so they would hold onto that patient for longer than they should with the things that they could do for that patient. And you know, there are examples of that where they don't have a particular service that is provided and I have to be careful here 'cause we're told we can't mention specifics, and so they treat them with the things that they can treat them with rather than send to specialised service perhaps where they've got other things they can treat the patient with. So if you think about, for instance, the Parkinson's disease pathway as a good example of where there are some medical interventions but there are also device interventions. So that would be perhaps a good example of that. And hopefully over time, I mean it doesn't matter that your patient, ultimately, it doesn't matter if your patient Huddersfield needs to go to Manchester because Huddersfield ICB will hold the budget for that patient and they will have to pay Manchester for that patient to go there. Whereas currently, the budget would sit in Manchester. Yeah, and that's where perhaps those sorts of frictions lie. What happens now when Huddersfield are working in the old system in theory, and therefore the budget still sits within Huddersfield and the patient is going to go to Manchester. Where for Manchester in the main, the budget will I guess sort of sit in Manchester for the Manchester area of patients. Manchester would also have been getting lots of patients coming in from other areas but the budget was still in Manchester. It wasn't coming from the other areas. And this is where it does get quite complicated. And I imagine when we had PCTs for instance, there'll be a single ICB that will be the main contractor for that Trust and they will manage these sort of incoming budgets rather than it sitting or Manchester Trust having to deal with it all.- To that point, I think what we share with colleagues is out there in the NHS, again, we're not intimately involved in this, but we guess people are trying to make their own senses of this and work out how they would do it. Yeah, so the way that we used to do it back with PCTs, I worked in a PCT and we led on specialised commissioning, yeah. Except for prison healthcare, which was a PCT that was near us where there was a concentration of specialist prisons and had a particular team. So there's going to be, people will be trying to work out how to do this and how best to do it and minimise the risk. But to predict bluntly Malcolm, is I went on LinkedIn earlier and said I can remember times when you'd have a four beded bay, the four patients from different areas in a tertiary hospital and there are different regimes of which patients could have what kind of treatment. I remember those days. Is there any risk that we would go back to that?- I would hope not. And that's where this oversight comes in and they, you know, they have to, and like I say, maintain the national standards, they have to meet the service specifications, which will be set at a national level. The clinical drive will come from the clinical reference groups for improving specialised services. And the budgets for the medicines and devices will be held centrally and allocated centrally when policies are published. Whether that's an NHS England policy for a specialised service, which, you know, quite a lot of the policies these days are for things like devices or whether it's a medicine, in which case normally that's a sort of a NICE guidance that's published and the ICBs will have to meet the requirements of those standards that are driven centrally. And the budgets as far as NICE go, I assume, reading between the lines, will be allocated on the basis of the NICE guidance going live, down to the relevant commissioner, whoever that happens to be at the time when that medicine becomes funded. And that's how it was working with specialised commissioning. I'm assuming that's how it will work in the future. What will change in some areas, you know, in the next few months following them going live in April over years is them looking at the budgets for their services and saying, how can we run this service better or how can we run it more efficiently? Or how can we reduce the requirement for this service by, you know, financing stuff upstream as we've discussed earlier, like diagnostics and screening and so on and so forth. And eventually those investments will result in a reduced need for some specialised services. Not all, of course 'cause some of these services are required come what may, but some may reduce in need and therefore the budgets will reduce and those budgets will shift and that will eventually include some requirements for medicines. However, that doesn't mean to say a NICE guidance doesn't have to be followed. What it means is, is that today, if a NICE guidance is published for some disease you might say, well eventually, you know, 200 patients a year will require that. And currently there's a prevalence population of 500, you know, but down the line,'cause there's been investment upstream, maybe it's only going to be 50 patients need that medicine. That's the direction of travel. So effectively there'll be a squeeze potentially on those medicines that are going to come out in the future where a requirement for them aren't needed or certainly it's going to be reduced.- Okay, and the first part of Malcolm's answer there, he is talking about the service backs, the CRGs, the CPAG. If you're thinking, I dunno what these things are. There was a really good document that NHS England and published on the 29th of November, which sets out a lot of the arrangements around them. And it, and it's a really lucid document. It's easy to read and it is full of really good sources. So look out for that. It's called "Methods, National Service Specifications". It's really good document and describe some of those systems, but I'm sure most of you in your companies are well briefed on those. So Malcolm, you've gone back to the companies.- Sorry David just, yeah, sorry. So the methods guidance isn't new, that's been around for some years, but it has been updated and probably takes into account that the service specifications for the 59 services are meant to be updated. And anyone who's heard me talk about this, I talk about the current service specifications, talking about the how and the what and the where, the new service specifications will still be kind of the what, what is required in that service specification or in that particular service, the how and the where are the things that will be removed because that becomes the remit of the ICB to determine where a service will sit and how that service runs and how that service is accessed and so on and so forth. But the actual, how that service is managed and set up and who needs to be part of that service and what the coexisting services need to be, will still need to be part of that national service specification. And those will have to be followed as part of that service and if the services meet those requirements and it can't be a specialised service.- Okay, you gave good advice which is, to our friends on the call, you know, don't panic. Another thing is most of the country is deferring things anyway, there's some intriguing parts of that just to add in. Many people know, I live in the northeastern Yorkshire region and some of our ICBs were very keen initially on pursuing early defaultment services. When you read the annexes, it's quite interesting. Our ICBs were judged by the moderation panel to be strong and mature, but they have chosen not to go forward. I'm not part of ICB decision making at a senior level. I can only guess that part of that was trying to work out the things that Malcolm and I are debating now, but perhaps most importantly that they haven't seen the real budgets and it's really quite interesting to see which ICBs has still gone for it. Yeah, but just to reiterate, the whole of London is not part of the initial change. So that leads me Malcolm to say, imagine yourself in a marketing team or there'll be people on the call here who are regional managers for companies affected. What can they do and are there different people they can see to get advice whether your territory is Huddersfield or whether it's Manchester or whether you're in a big London teaching hospital or you're wondering now what is the border of Midlands and does it, does that mean Sheffield or Leicester is in, you're trying to work it out. What's your advice to those companies? What would you suggest they do over the next couple of months?- Well, first of all, go to the website and I have a look at what it says, understand what the 59 services are that are moving and then you can identify the medicines that are going to be impacted by that or devices. And once you know that, you can then set out a strategy. I wouldn't personally be thinking too much about your existing medicines. So the ones that are there already are those that are funded already. You're not going to see a massive change. And certainly the services that currently prescribe those medicines are going to continue to prescribe those medicines and will continue to have the budgets for those medicines. Because as we've already said, this convergence of the funds to this population based or needs-based system will take some time. So I wouldn't necessarily be too concerned about your current portfolio. I think what you do need to concentrate on is anything in the pipeline. And I'd be probably looking ahead towards 25, 26 for when you're going to go through NICE to determine A, whether it's impacted by those services moving and then B, putting together a list of people within ICBs that you need to contact. Now, I don't know the specifics. I imagine there will be somebody who has overarched responsibility for medicines management within the ICB. Within this document incidentally, it talks about what's going to happen to the NHS England hub staff and they are going to transition across to the ICBs over time. Some will still be maintained at the regional level'cause they're still highly specialised and other services that are going to stay centrally managed. But there'll be somebody, I imagine, who is in overarching control of medicines management. And that's, to my mind, the person that you should target. If your medicine is particularly one that's going to impact healthcare resource, which I think is important at this point in time'cause of let's say the mess that the NHS is in, then you'd be wanting to perhaps try to maybe get in to see the finance director or the medical director if they're willing to see people from the industry to talk about how you can impact this pathway through the use of your particular medicine versus anything else that's available. Or maybe you're the first medicine for that particular disease and you'll be able to show them how you can shift resources to invest in, better care, whether that's upstream or around the use of your medicine, but clearly that it releases capacity within the system. Be that nurse time, pharmacy time, bed time, GP time. And you need to start looking at those sorts of models and almost forget about the clinical benefit. I know this sounds really bizarre, but the fact you've been through NICE, NICE have said you're cost effective and obviously clinically effective. You know, that's almost a given. But what isn't a given is your wider impact If you have those things. And those are the things I think you need to sell to the NHS moving forward. And like I say, go into the ICBs and think about the whole pathway and how you can impact the whole pathway.- Yeah, and I think companies, diagnostic, device, drugs, have been teased with that prospect. And some of what we've said today about ring fencing and moving upstream would scare people think they're going to lose from that. I'd encouraged people to be optimistic as you just done and to say, yeah, some of the questions that were pre-submitted were really good ones about the difference of value and cost. This is a chance, isn't it? To say that we've got value, that in a sense that, I don't know, I know we can't be too specific, but something for a certain condition eventually can reduce the demand. Unfortunately there'd be plenty of people with that condition now, but over time it could really show a health economic benefit. I'm with you but I think as you've done, it's difficult to see who they'd actually talk to beyond some of the chief pharmacists. My advice pipe, and I'd be interested in what you say here, Malcolm, people who immediately be interested in this is the big tertiary Trust chief pharmacist, medical directors, finance people.'Cause just remember everybody, if you take a big tertiary hospital like, Newcastle Hospital down the road from me, 2/3 of their income is specialised services. Okay, so that's another reason why I think some areas have delayed because they're worried about the risk with their big hospitals. But I wonder what you think of this Malcolm. There's clinical networks, there are national groups of societies, there are things that are coming out of various diseases, whether it's various societies and things and clinical networks of course are reproduced locally. Would you go to them? I'm just leading the question already. I think this is an opportunity for them to go to their ICBs or to go across the region and to say, look, we really got great ideas here about renal care or haemophilia or whatever the specialised condition could be, autism, whatever. If they're constructive at the moment, proactive, this could be a really great opportunity.- Yeah, and again, one of the things that the ICBs have been instructed to do is to not only maintain but to grow clinical networks and to fund those clinical networks. So to my mind, the Trusts are easy, inverted commas, because clinicians want to prescribe new drugs in the main, and my assumption is, as was happening when I was at NHS England, Trusts will be advised of when budgets will become available for the NICE guidance medicines. I think the key thing with Trusts are if there's going need to be some investment at the Trust level in order to access a particular medicine, whether that's how it's given or maybe's a company diagnostic with it, which is not currently funded, then those are the sorts of things where companies probably need to go into Trusts and effectively support those Trusts with business cases for instance. But equally, it's the ICBs that ultimately hold the budget for high cost drugs.'Cause these drugs are passed through, although as most of us hopefully know, specialised commissioning decided after all the medicines were put into a block contract in April 20 that some of those drugs would remain in block and then the rest of them went back to pass through and 80% of high cost medicines in volume stayed in the block.'Cause a lot of it was old chemotherapy. And then the other 20% went back to pass through. But actually that's 80% of the budget.'Cause these are the really high cost drugs. And so particularly where you've got competition for your medicine and maybe particularly where you're second or third into the system, I think, and you have some of these benefits I mentioned earlier. That's where I think perhaps the ICBs the better place to target because the Trusts will say, and pretty much all new medicines going through NICE now will be in the pass through side of this equation if you're a high cost drug. So it's pass through. So in many ways the Trusts on that first, they'll say, well if we use this medicine, we're going to get paid because the commissioner has to pay us'cause that's a legal requirement. Whereas the ICBs might be looking to, I say release capacity, invest elsewhere and your particular medicine that's coming in is a medicine that can do that sort of thing. It's oral instead of IV, it's a medicine.- Out of my mouth.- Rather than yeah, rather than having to be in the hospital. It's a medicine with fewer side effects or it has less interactions or whatever it happens to be. The key point is, is that the ICBs won't necessarily know this. The Trusts are more likely to know it, but they're less interested because like I say, they're going to get the money regardless. And so that's why I say you should target the ICB as I say the individuals we don't know, but there will absolutely definitely be either a senior pharmacist or a medicines management type lead that the companies can target.- Yeah, when you cut through all this uncertainty and we've got 10 minutes left, we'll probably have a bit more uncertainty in a minute. It's when we come, I'm with you that you've got to be constructive and positive and think of things like that. You've got a drug that's subcut instead of IV. You've got a drug that doesn't have to be reconstituted. Something that doesn't have to be in a fridge. You know, something that I don't have to travel 100 mile round trip to go to a tertiary hospital every day to have the treatment. There's some really intriguing stuff here that could change value propositions on quite a local level.- And just for other colleagues on the line and interventions, devices that can be done overnight in a hospital rather than a patient having to be in hospital for days for instance. You know, there's these sorts of things that coming into the system and obviously, you know, as we move forward, things that can be managed through virtual clinics, things that can be managed through AI and you know, data apps where patients can be monitored remotely rather than having to keep going into hospital to have bloods taken. All these sorts of things that are coming through that the industry both on the device side and the medicine side can develop and support.- And funnily enough, I've got a text today that shows exactly what you say from my own practice. I live in a rural valley. It extends about another 40 miles past where I live in very rural area and we're now getting a bus which can be used to administer treatments including the shape and it comes with an artist's impression that suggests that it could be used for IVs and all kinds of complex stuff. So as to say, I think this is a great time to be around diagnostics or digital. It's not just the drugs, but, you know, let's not forget the drugs. I've got a very specific question. Let's do at least two minutes on this. What does this mean for Wales and Scotland, Northern Ireland, but particularly, I'm thinking of Wales. Wales, a large part of Wales now joins within a part of England that is part of the initial devolvement in terms of the Midlands. I took part in the session once and there was a collision on from the Isle of Man who was saying, well don't forget about the Isle of Man. Our tertiary care goes into, I think it's Liverpool, isn't it? And we're really cut off a lot time from the communication of this. What what's the impact on the devolved nations in themselves?'cause they're not mentioned this, this is an English policy I think, isn't it entirely? But what about patient flow? In my practice we've got 600 patients who live in Scotland.- Well, no change as far as I know, I mean, Wales and Scotland and Northern Ireland, and I don't know about the Isle of Man, but the, you know, they don't have commissioners. Their systems are completely different to England and their budgets are managed through their health boards. And if a Welsh patient goes into an English hospital, then they fund that patient. And of course, Wales and Scotland have things that they fund that England don't and vice versa. So if Liverpool for instance, does a particular service and that service is required by somebody from Wales or indeed the Isle of Man, then it's the Isle of Man and or Wales who budgets for that person going into that English hospital. And indeed vice versa, if an English person happened to go to Cardiff say, then that ICB will need to fund that patient.- Yeah, there's complex arrangements. I'm sure, if you're a key account manager and you're along the borders, you'll know much more about them than me and Malcolm. So now I'm coming at the end, but I want to ask you questions. It's, what do you think the response will be in the NHS if you saw this through? Let's imagine we had a crystal ball and we're having this conversation again in 18 months. What do you think?'Cause a lot of what you said suggests nothing amazing is going to change too much too soon. But will that be the case and have we not covered things that we should have covered? This is your chance.- Well, there there is one massive elephant in the room, which is there could be a change of government.- Yeah.- And that's going to happen in that timescale, if it happens, of course, and we don't know what the plans really are for the NHS, if, let's say another party takes on the government rule and there could be a complete U-turn as far as I know. But let's say that doesn't happen, then in an ideal world, eventually the budgets will be in the right place according to the populations that each ICB manages. The 59 plus whatever other services are identified have moved across in full, including the medicines budgets. But don't forget, still likely to be managed centrally. The ICBs have the freedom to shift moneys around from specialised services to invest in that pathway. So this is an important point. They can't just shift moneys from, let's say specialist diabetes over to maternity services. I'm not sure that that would be allowed. What they could do is shift moneys from specialised diabetes, the pathway to, as you say maybe prescreen.- Weight loss programmes or.- Or prescreen diabetics, you know, they're called pre-diabetics. It's a new that's coming through, and, and they could intervene to try and stop them becoming a full diabetic for want of a better phrase.- Could they use it to fund more use of flash drives?- Yeah, of course, of course. I mean, like I say, I think the idea is, is that they look at a particular pathway and they can shift the moneys within that pathway, including medicines budgets eventually. But they couldn't just say, oh, you know, we need some more money over in this completely different service which isn't even specialised and has ever, ever been anything to do with specialised, unless of course that particular service can impact this particular specialised pathway that they're trying to improve. So that's kind of, sort of where I would see us hopefully ending up. And then the idea is that interventions happen earlier, equity is driven up, outcomes become better. And there is still, and certainly there was talk when I was there of this, of looking at changing the way the NHS is funded completely. And there's some, and I'm sure colleagues on the line are fully aware of the VPAG announcements from last week about looking at improving data flows, looking at providing sort of pathways for patients so they understand what's available better. And pretty much driving improved uptake of medicines to allow better access. Now, like I say, ultimately, I think the goal would be to try and stop the need for some medicines by earlier intervention such as surgery and perhaps use of devices and screening and diagnostics and so on and so forth. But that is a long way down the line.- Okay, and at that point, I know we've got a minute left, I'm going to hand back to Jennie to give the courtesy. So thanks for Mtech Access for helping us put us on, we won't have covered half of what needs to be discussed and I'm sure there's ways that you can follow that up with Mtech Access at subsidiary sessions specifically, or generally. And just to reiterate, if you think sometimes we've been vague, I promise you we haven't, go back and read the thing and you have to hold it up carefully to the light and interpret things and we'll be really keen on hearing your views, over to you, Jennie.- Thanks David, well, I'd like to start just by thanking both of you, David and Malcolm, on behalf of everybody that's kind of tuned in to listen to you today, you've given us some really invaluable insights and have really illuminated the intricate facets and complex nature of specialised commissioning, which I think is going to continue for a while. As we start to bring our webinar to a close, I wanted to offer all participants the opportunities to work with Mtech Access, to delve deeper into what specialised commissioning changes mean for you and your business, whether that's at a product, asset or organisational level. We're also able to provide you with real world examples using your own product portfolio to create unique case studies to support understanding of where your product sits within the wider world of specialised commissioning, but also within the NHS funding scheme as a whole. And these case studies can help you to identify key stakeholders and navigate the ever-changing NHS landscape. If you would like to talk to us, as David said, regarding more details what we discussed today or any of the services I've just mentioned, then please do get in touch with us, as well as us being able to support you and keep fully abreast of NHS policy changes in real time as we've managed to touch on today's talk. So if you could drop us an email, our email address is info@mtechaccess.co.uk. So thank you once again all for joining and I look forward to launching our 2024 webinar schedule shortly. So please do sign up to the newsletter so you don't miss out on these valuable events. Goodbye for now.- [Narrator] 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.