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Insight: Raising the bar

Insight: Raising the bar

4 June 2014

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Joint working with the pharmaceutical industry has enabled East Surrey CCG to deliver better outcomes in alcohol-related illnesses.
There is much debate about whether clinical commissioning groups (CCGs) should partner with ‘industrious organisations’ whose market is the NHS. One such industry that gains extremes of media attention, sometimes favourable, sometimes not, is the pharmaceutical industry. Whether you like them or not, they are key suppliers which operate in our health economy and certainly contribute to ‘UK PLC’. Perhaps it’s fair to say they are no different from any of the new service providers we commission who are equally industrious independent businesses supplying ‘products’ to the NHS. We must not fail to recognise the fact they are all providers and we buy their products and services, and as such we hold a significant amount of power over them to negotiate a fair deal. At East Surrey CCG we seek to form close and mutual partnerships with our suppliers and have worked on several joint working projects within the Association of the British Pharmaceutical Industry (ABPI) Joint Working Guidance, supported by the NHS Confederation and Department of Health (DH), which have made a significant difference to patient outcomes in our area, in asthma, chronic obstructive pulmonary disease (COPD) and more recently, alcohol.
Alcohol consumption accounts for around 10% of the UK’s burden of disease. It is one of the highest lifestyle risk factors for disease and death in the UK, after poor nutrition, smoking and obesity.1 Alcohol dependence in the UK is significantly under-diagnosed and under-treated with only 6% of alcohol dependent patients aged 16–65 years receiving treatment each year.2 We estimate that alcohol-related harm annually consumes nearly £12 million of the CCG’s commissioning budget. Despite this, there was no priority for alcohol, no service specification around integrating care and no quality, innovation, productivity and prevention (QIPP) focus to reduce healthcare consumption. Not only this, alcohol has been included in a wide range of outcome indicators at a national level.
There are a number of lessons from our partnership approach in alcohol which may be worth sharing. 
Lesson one
If you are going to enter into joint working, be sure the project is a priority area for local people and your organisation
For alcohol, we signed an ABPI Joint Working Agreement with Lundbeck Ltd who are a supplier to our CCG of pharmaceuticals for mental health and brain-related diseases. As co-chair of the Surrey-wide health and wellbeing board (HWB) and also chair of East Surrey CCG, I was aware that alcohol-related harm and alcohol consumption was a key issue to our health and social care economy. In fact, colleagues in public health were very concerned about the high number of people who were causing themselves harm, increasing their risk of developing long-term conditions and, in many cases, developing moderate and severe levels of dependence without becoming known to services until it was too late. The local acute trust gastroenterologist was expressing concern about ever-increasing amounts of liver disease in his workload, and that many people arrived into the trust with no recorded history of alcohol dependence.
Lesson two
Be sure the partner brings expertise that can be synergistic to your local population and organisational needs
We were approached by Lundbeck Ltd, who had been working on a new drug, Nalmefene, indicated for the reduction of alcohol consumption in adults with alcohol dependence who have high drinking risk levels without physical withdrawal symptoms and do not require detoxification. This was a quite a tightly confined licence group, which we were able to quantify. They were seeking to find and support service developments in alcohol to benefit patient outcomes and help identify those drinking at higher risk levels. Clearly, for them, identification would open up markets in which to launch their new drug. 
Alcohol attributable hospital admissions have been increasing year on year in Surrey and have almost doubled since 2002.3 The overall prevalence of increasing risk drinking in Surrey is approximately 21% and higher risk drinking is 6%. While comparable to rates both nationally and regionally, these estimates suggest that more than one in four adults who drink alcohol in Surrey do so above the recommended levels. In terms of actual numbers, this translates to around 164,898 increasing risk drinkers; 50,498 higher risk drinkers; and 164,546 binge drinkers within the county.  In addition, there are an estimated 21,671 moderate to severely dependent drinkers in Surrey; with 1969 clients recorded in structured treatment for 2011-12.4
Lundbeck were able to provide robust health economic analysis which complemented existing CCG or HWB-level data. As many of our pathways for long-term conditions were robust, this was certainly something we wanted to review at a CCG level, and to meet efficiency savings targets in. Strategies around preventing health and improving wellbeing is an increasingly important part of our work. However, as a new organisation, our analysis and understanding of health economics around prevention and commissioning was not a core competence. It was clear to see that as the third highest risk factor for disease, alcohol caused a significant impact on the health of our population locally.
Lesson three
Make sure the individuals involved are high calibre and can build trust and relationships
In a new untapped area for CCGs like alcohol, we were short on internal alcohol commissioning expertise. As part of our joint working agreement, we decided to offer a secondment to an individual from Lundbeck Ltd who we felt could bring in expertise and relationships. Lundbeck’s Regional Account Director had developed some strong business cases, understood commissioning and had made some excellent relationships with the majority of key stakeholders, building trust and partnerships with Public Health and local authorities. 
Lesson four
If you are going to work in partnership make sure the you integrate the partner
We aligned a commissioner to work internally with the seconded director, to ensure there was a clear project plan and outcomes to design and deliver a new service specification and pathway. We built and signed clear terms of reference as part of the agreement, enabling the secondee to work inside the organisation, alongside all our key functions. As alcohol was a new commissioning area, it was important for the project to take our other functions on the journey. For example, we used the project as an equality and diversity training case study which helped spread the awareness of the secondee, the alcohol burden and helped us build support for the quality of the work inside the CCG.
Together, the CCG and secondee worked with Public Health to produce a business case to help us better understand the size of the impact of alcohol, and how improving identification, screening and integration around treatment across health and social care could drive some strong efficiencies. We were impressed at a governing body level by these aspirations. Despite recognising that any work in this area may incur some increased spending in a small group of people who may choose a pharmacological approach to help them reduce their drinking, there were some real and sizeable opportunities to reduce risk and improve outcomes (and spend) for us as a CCG. The benefits would also extend to many other health, social care and emergency services. 
Lesson five
Be clear on what the benefits are for patients, all joint working organisations and others beyond
People and patients must be the first beneficiaries. It was clear that by improving our service specification and integration with other commissioned and voluntary services, that people in our area would benefit from understanding the harm alcohol was causing them, and also that those who knew they had a problem knew who could help. Through engagement, the secondee was also able to help many organisations in the health and social care environment see benefit. A new audit C scratch card approach to drive awareness was agreed with partners, which we hope will be given out by hospitals, GPs, probation, domestic abuse, adult/children’s social care, dentists, police, housing and others to help education and signpost people to a confidential Freephone helpline. This service then better understands risk, gives advice and, where required signposting to a new GP/community pharmacist service which will give screening and brief advice. Not only this, better hospital liaison services including a new post, were agreed with the acute trust. From a Lundbeck point of view, Nalmefene, their drug licenced for treating mild alcohol dependence, was built into the pathway in an evidence-based and acceptable budget case, alongside the other drugs for managing dependence and withdrawal. 
Lesson six
Give the partner an environment to succeed and don’t be surprised if they do
It was clear to us that the pathway work was a real strength, but we were unsure how we were likely to fund the new service developments. At the beginning some stakeholders within the CCG were reticent to partnership with pharma. We had to work hard to build trust, and we involved a lay member who reviewed all our agreements and actions and declared them robust. As a partnership, we knew that to ensure these services were respected and trusted that any pump-priming we needed would need to come from the NHS. We needed also to ensure that we were able to realise the efficiencies in our business cases, and then seek to ensure the services were self-funding moving forward. In our own tight financial envelope, we knew this would not be possible, so we approached the Academic Health Science Network (AHSN), who despite being touted as the linking agent between health and social care and the industry were not able to support us in any way. Fortunately, we were able to secure excellent support of our strategic clinical network (SCN), who recognised that pathway work in alcohol spanned many of their priority areas, including cardiovascular disease and mental health, and after presenting a business case, they awarded us a programme budget of £182,000.
Lesson seven
Make the partnership wide and lasting
As Lundbeck had helped us so effectively with the pathway work, once we had funding for implementation we offered to continue the joint working agreement, seconding in Lundbeck to support us with the implementation phase of the project. We have been very impressed how in just six months we have been able to produce the first CCG-led integrated service specification pathway for alcohol. Lundbeck have acted with high integrity, been very professional and brought a new and beneficial prevention workstream into the organisation. While we understand and accept they may have a future commercial opportunity from the pathway, as people who fit into their drugs licence may now become identified by the new services. But we are clear across the health and social care environment that the major beneficiaries for the future are the people and patients whose risk levels are unhealthily high. We now have a bigger integrated net to catch risky drinkers and seek to support less people to develop dependency to alcohol. We would like to thank all our partners, Lundbeck Ltd, Surrey Public Health, Alcoholics Anonymous, Surrey and Borders NHS Partnership Trust, SAdAS, Catch 22, Tandridge Borough Council, Reigate and Banstead Borough Council, Raven Housing Trust, Surrey and Sussex NHS Trust, South London CSU, SEC Ambulance, Babcock 4S, Surrey Police, Surrey County Council, First Community Health and Care and many others for the support in developing this partnership around alcohol.
As a final point, we would certainly encourage commissioners to engage with pharmaceutical suppliers in an open, transparent and partnership-orientated way utilising the ABPI Joint Working Process. It gives an excellent framework, clarity, governance and opens up innovation to improve services.
Dr Joe McGilligan is the chair of East Surrey CCG and co-chair of Surrey Health and Wellbeing Board.
1. Balakrishnan R et al. The burden of alcohol-related ill health in the United Kingdom. J Public Health 2009;31(3):366-73. 
2. Alcohol Concern. Investing in Alcohol Treatment – Reducing Costs and Improving Lives: Alcohol Concern’s learning from 10 years of consultancy and training. 2010.
3. NHS Surrey (2009-2012) Surrey Alcohol Strategy.
4. North West Public Health Observatory (2012) Local Alcohol Profiles for England. 

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