No-one can be unaware
of the strains and tensions gripping primary healthcare in the UK, with
frequent reports of sub-optimal care delivery, lack of resource both in terms
of cash and personnel, and the never-ending feeling that the current model of
primary healthcare is simply unsustainable.
All of this is
leading to the desire for change, and to actual change – in a real, fundamental
way that perhaps we have not seen before.
And as with any change in the healthcare system, this is something with
which pharma is going to have to get to grips.
The NHS England
Report Five Year Forward View (which
does exactly what it says on the tin) makes it plain that the existing model of
primary care cannot support a number of critical transformations in primary
healthcare.
Perhaps the most
challenging change is demographic: with an aging population, primary care is increasingly
dealing more with treatment pathways of chronic care involving multiple disease
states.
At the same time, the
demographics of GPs themselves are evolving. Older partners are retiring and fewer of their
younger colleagues want to step into their shoes, preferring salaried positions
or part-time roles in order to maintain a good work life balance.
Unlike in previous
eras, more than half of GPs are female, and many of them will quite rightly
expect to be able to combine their careers with parenthood. In fact, GPs in general want a more flexible
working environment which gives them time for family and play - and why not?
Meanwhile, patient
needs are changing, driven by a greater determinism to move healthcare away
from acute secondary services towards primary health, and by rising
expectations driven by the ‘patient centric’ mantra of modern healthcare, which
exacerbates the current dissonance between the existing nature of primary
health and its delivery.
And we can’t ignore
the economics of primary care. The ever
increasing costs of managing disease are not entirely the result of increasing
medicine costs, but rather our increased knowledge and technologies which are
enabling us all to live longer.
Framing The Future
For once,
professional bodies and GPs themselves are in agreement, that structural change
in primary care is essential if it to remain free at the point of care (and
this, we know is always up for debate).
Already three significant trends are emerging which are likely to frame
the future.
1. Bigger is better
The days of small
practices with two or three partners are numbered, with a move towards larger
and even ‘super’ practices, whether in
situ or via federations. Whilst the
exact picture will vary according to local needs, the rationale behind this
trend is common. The devolution of
certain secondary services to primary care, alongside access to the provision
of broader mental and social services can only be resourced through the
economies of scale of large practices, able to employ primary allied healthcare
specialisms. As increasing numbers of
partner-owned practices start to lose money, the unsavoury yet necessary
premise of 'providing the cheapest primary care service possible' comes to the
fore.
2. Division Of labour
In effect the current
model still focuses on the GP as the central access point. But the professional competencies of other
allied professionals, such as diagnostician and prescriber and manager are
growing; similarly, pressure continues to grow to devolve some decision making
to pharmacists who may be better able to make decisions for minor ailments. Meanwhile, GPs still ideally want to follow
the patient’s treatment pathway, and be autonomous practitioners and central
points of access.
3. A different form of leadership
Leadership in primary
care has often been cited as a missing ingredient (some might argue it’s an
easy cop-out as well!). Finally, there
is an acceptance of the need, if GPs are to continue their primary role as
clinicians, for someone to manage, triage more effectively and delegate aspects
of patient care to reduce the burden on GPs. Whether this should be a GP or other
healthcare professional is a contentious issue.
What Does It Mean For Pharma?
First of all, the
number of key decision-makers is likely to continue to reduce. This means each one will hold bigger budgets,
and will be juggling the medical, social and mental needs of the community. They will also most likely be handling more
services previously provided by secondary care.
For pharma, this means
an increasing reliance on senior negotiating and sales skills with greater
freedoms to provide deals to larger stakeholder groups, and understanding the
wider picture of healthcare needs.
Much as primary care
providers are already starting to do, pharma urgently needs to grasp the fact
that the greater proportion of patients now come in with multiple chronic
disorders. Too often sales calls focus
on an assumption of episodic disease, whilst doctors are dealing with multiple
disease states.
Added value offerings
and care management programmes will need to take this into account to be
meaningful to customers. This may mean
greater collaboration with other companies in unrelated disease areas. It is also a great opportunity to consider
appropriate algorithms of care that take into account your asset in different
multiple disease states (for example, how does your asset perform when the
patient is diabetic with heart disease or COPD?). It may also reflect how pharma conduct
clinical trials in the future and personalised medicines management.
Primary care should
be the arena in which digital frameworks to improve healthcare access,
information dissemination, the provision of monitoring and providing healthcare
advice, really gain traction – but they remain underdeveloped. This is definitely an area in which pharma
can help.
Medical records are
progressively moving into a broader domain (eventually they will be available
to the patient) and this will provide unrivalled opportunities to integrate
digital monitoring of care.
Will we see the day
when a diabetes video consultation service sponsored by a pharma company has
helped ease the burden of management? When
a patient uses an app to make a request, record, monitor and manage their own
blood results? I would say yes, and
pharma needs to be right in there helping primary care providers to achieve
just that.
Finally, a more
existential change is happening to primary care. As larger practices take increasing
responsibility for delivering what has up until now been the exclusive domain
of secondary care providers, the lines between the two will become increasingly
blurred.
Pharma’s current
silo’d focus on primary and secondary care must follow suit, otherwise our
industry will be seen as increasingly disengaged from what is happening at the
coalface of healthcare delivery – which is, and will become even more so, the
primary care provider.
The View From The
Consulting Room
The themes contained in this article were put to a number of GP senior partners around the East
Anglia and London area. Their views were
even starker than those in the NHS England Report:
- Partnerships will be a thing of the past. Larger super practices will take over, where
GPs will act as primary clinicians and clinical leads, supported by a
multi-disciplinary team. Management may
effectively be supported by CCG funding. Federations will develop to ensure everyone’s
voice is heard.
- In all likelihood there will be fewer rather
than more GPs. Current estimates would
suggest that whilst the government attempt to recruit 5,000 new GPs, more than
10,000 are likely to leave in the same period.
- The rising burden of complex multiple
conditions means that consultation times will have to change to accommodate
chronic disorders. Many practices are
looking now at different models of management; simply put, a patient with a
list of 11 conditions cannot be adequately cared for in a ten minute
consultation.
- Changes in health electronic systems and
wider access to patient notes will likely place an ever increasing burden of
data provision, leading to a greater need for digital algorithms to prioritise
treatment and management. Similarly
these systems will need to take into account individual, complex multiple
treatment pathways to maximise care and minimise error.
- All agreed that what we see today will change
markedly in five years time!
The Author Paul Mannu is Behavioural Insights Director at Cello Health Insight. He can be contacted at pmannu@cellohealth.com. Twitter: @pmannu This article was first published on Pharmaphorum.com in August 2015