James Roach and Johnny Skillicorn-Aston present an interesting case for localising the work of the Accelerated Access Collaborative
Innovation in the NHS can be characterised as stop-start, often resulting in an unacceptable lag between invention and inception. Failure to capitalise on advancements in health science and technology has, at times, held back transformation and limited the rate at which innovations can be turned into patient benefits.
Published in 2016, the Accelerated Access Review (AAR) set out a new multidimensional vision; in fact, a 4-D vision.1 Its areas of focus were:
- digital products.
These areas of focus represent prime drivers that will carry innovation through the system, bringing tangible benefits to patients and improving the UK’s position in the international life‑sciences sector. The recommendations of the AAR led to the establishment of the Accelerated Access Collaborative (AAC), which has the objective of driving the uptake and adoption of innovation in the NHS.2
This year, the remit of the AAC was expanded and, under the leadership of Dr Sam Roberts, it will become the umbrella body for health innovation, supporting innovators, and setting strategy.3 Its new chief executive has been open about some of the challenges the NHS faces when it comes to pushing innovation through the system. In May 2019, she cited funding, custom and practice, and ownership of innovation within the system as among the issues to be tackled.4
AHSNs: the key NHS transformation arm
While improving funding requires putting incentives in the right place for innovators, providers, and commissioners, and altering custom and practice requires changes to healthcare roles, procurement, and clinical settings, ownership needs to be a core responsibility so that good innovation can be identified and spread. This is now the role of the Academic Health Science Networks (AHSNs).
Failure to capitalise on advancements in health science and technology has … held back transformation …
Established in 2013, the AHSNs serve as a bridge between research, the life‑sciences industry, and healthcare, and aim to straddle sectoral boundaries. Although relicensed in 2018 as the key NHS transformation arm, their role has been criticised in the past on the grounds of being poorly defined and ‘short-termist’. However, now central to the ambitions of the NHS Long Term Plan (LTP),5 the AHSNs are set to bridge the gap between formal (top-down) and informal (bottom-up) pathways to innovation uptake.
Localising the work of the AAC
Specialised commissioning is one of NHS England’s five areas of commissioning responsibility, but its impacts and outcomes are felt by patients at the local level. The budget for specialised services was almost £17 billion in 2017–18,6 representing 15% of the £110 billion total NHS budget for 2017–18.7 It is this scale that makes the work of the AAC ever more important for specialised services.
It is this scale that makes the work of the AAC ever more important for specialised services.
Innovation and transformation at a centralised and national level lacks meaning unless it is influenced by local dynamics. Converting life-sciences developments and innovations into life-changing outcomes is a central objective of the LTP,5 and the prime agency in this is the AAC. Through supporting the rapid uptake of seven innovative technologies, it aims to give patients faster access to treatments with the potential to improve up to 500,000 lives and achieve £30 million in savings to the NHS.8
What happens in specialised commissioning, especially regarding collaboration with the pharmaceutical industry, will be profoundly important in demonstrating achievement following the announcement of these ambitious plans. The repository of experience and real-world evidence will increase the rate of innovation, develop and finesse further transformation, deliver better outcomes, and reduce health inequalities. Localising the value of this work is critical, and medicines represent a great opportunity to do this. Although we now have a 4-D view in play, innovation in the NHS has been viewed through the twin lenses of ‘device’ and ‘procedure’ for some time now. Some would argue that this has resulted in medicines becoming the poorer relation.
Working in partnership with the pharmaceutical industry
Recently, NHS England indicated its outlook on innovation and the pharmaceutical industry.9 Addressing the NHS Confederation conference in June 2019, NHS England Chief Executive Officer Simon Stevens said, ‘Preparations are under way to make sure the NHS can adopt the next generation of treatments’. Although qualified by a caveat around price, the opportunity is clear within specialised commissioning. It is an area that is ripe for medicines innovation and optimisation that will contribute to the transformation and savings the NHS wants to achieve as part of its LTP.
Adoption of biosimilars
One area of opportunity within the LTP is establishing a firmer position for biosimilars in the medicines supply chain. This is illustrated by the ambition of NHS England’s Commercial Medicines Unit to achieve maximum value within the increasing spend on medicines. The scale of this ambition equates to a saving of £300 million per year by 2021,10 and patients within specialised services, and the treatments they receive, is an area in which biosimilar medicines can achieve savings that can be reinvested in front-line services.
Barriers to localisation of the AAC
The key to unlocking this potential is the strength of local system relationships—engagement with patients at a local level. In other words, using data drawn from the experience of healthcare professionals, managers, and patients to develop a cutting-edge population health model that draws out the clinical, financial, and social benefits of delivering transformation.
One of the challenges of doing this is that the local picture can be just as disparate as the national one. Attempts to address the institutional disjointedness at a national level have prompted the merger of NHS England and NHS Improvement;11 at the local level, moves to establish Integrated Care Systems continue.12 However, bringing together organisations to work within a commonwealth for a common good is a goal yet to be achieved. This is amply evidenced by the fact that there has been relatively little connectivity between the NHS, academic organisations, local authorities, the third sector, and industry.
The role of AHSNs in localising the AAC
This lack of connectivity is now being addressed by the AHSNs.13 The AHSNs are an ideal vehicle for socialising and localising the aims of the AAC within health systems: their ‘small-organisation’ model makes them responsive to identifying and adapting to emerging opportunities and challenges. Operating across a regional network, they can bring human and system resources together quickly to support innovation that improves patient outcomes, returns value into the NHS, and promotes economic and market growth.
The future of the AAC
The AAC is charged with horizon scanning to identify future innovations that will yield the greatest benefits to the NHS and its patients. Another of its duties is to act as a signalling post of national NHS priorities to researchers and innovators. The AHSNs provide support at the local level, their national reach and linkage between NHS, academia, and industry driving both innovation and service improvements.
Having a test-bed approach is the cornerstone of innovation, and this is critical for collaboration between the NHS and the pharmaceutical industry. Understanding the value of new medicines—not just in terms of the clinical impact for patients, but also in terms of the plus-factors of increased wellbeing and social and economic capital—is important in a changing NHS.
Accessing the patient experience
Working with local data provides an opportunity to analyse from the bottom-up and identify impact where it is felt most—in patient gains. Engaging with patients around where this may steer future innovation at the local level commits commissioners, providers, and patients to a shared enterprise. This helps translate the grand strategy of innovation into a universally intelligible language of benefits and improvement.
Evidencing cure—the rate at which morbidity and disability are reduced or constrained, and the longevity of this impact—requires a joint approach at a local level around case-finding and patient management. Although the NHS is multipartite, patients largely view it as a single entity. Patients expect and deserve optimal care, but we must understand what suboptimal care is before we can achieve optimal care. Although great advances have been made in the co-design of care pathways, we need to accelerate the rate at which we operate in partnership. Being open and honest about what is working, in the interests of system convenience and organisational sovereignty, is crucial. To coin a phrase, it’s not rocket science! Access to the patient experience has never been more available; however, we tend to involve patients only after we have determined an approach. If we are throwing open the frontiers between academia, industry, and the NHS to forge a new transformational landscape with innovation superhighways, then we can do the same at the local level. Patients deserve to be consulted the moment the thought of pathway redesign or reconfiguration enters the head of a local commissioner.
Having a test-bed approach is the cornerstone of innovation …
A quick scan of who is out there reveals, at the representative level, Healthwatch and a plethora of patient groups and voluntary organisations and, at the individual level, patient participation groups and networks. It is within this space that we can drill down into the felt experience and compare with what the activity and outcome data tell us. In doing so, we move ourselves closer to the patient and place the patient at the centre of our plans and schemes. For specialised commissioning, it represents an opportunity to distil what is done at scale into an essence of what is experienced.
Another element to securing localisation is engaging with impact, and this means bringing patients and patient groups into the innovation dynamics. The advent of population‑based health brings with it shared responsibility for improving the health of an entire population, traditionally within the purview of public health. Now, however, a broader coalition of responsibility exists for this and the wider determinants of health. Patients and their experiences are key to this work, and just as we now look at the negative impacts of challenging social factors, limited economic status, poor housing conditions, declining emotional wellbeing, and lack of social capital on population health, equally we must consider the positive registers in these areas when we are assessing and defining the value of our innovations.
This should also direct us towards greater ambition in how we incentivise populations, providers, and innovators to share in the definition and expression of value. The NHS is founded on social principles, and its social impacts are a legitimate area for innovation. As we interact more openly and equitably with industry, there is an opportunity to engage on corporate social responsibility agendas. Social Impact Bonds14 provide a vehicle for a share of efficiencies, savings, and gains to be pooled and redirected into communities to further support social capital and underpin wellbeing in our communities.
Outcomes for specialised services
Of course, bringing people and resources together means that we must be bold, generous, and expansive in how we share the risks and rewards of pushing current boundaries around how we operate. We must be ready and able to articulate benefits that may not be ‘cashable’. Developing pharmaceutical regimens for cohorts of patients within specialised commissioning who have complex histories and needs will mean a common focus on, and ownership of, savings that are capitalised elsewhere. However, such a utilitarian approach already has proof of concept by the very existence of the NHS, which hinges on getting people to pay for something that they might not need to use. Therefore, the pooling of risk and return is not an alien concept.
We must be ready … to articulate benefits that may not be ‘cashable’.
Returning to the situation in specialised services, adopting biosimilar medicines may not provide an opportunity for local commissioners to capitalise on savings in that area of spend; however, wider gains exist in the impact on patients of medicines that offer efficacy and fewer interventions. Often, this will result in the rehabilitation of the patient’s economic position, reducing reliance on benefits. It will save money elsewhere in the system through reducing scans, testing, outpatient and GP appointments, and waiting times.
Innovation is an iterative process, each stage suggesting the next and creating a continuum of learning, transformation, and impact. It requires the raw materials of experience and data, and patients are the root of both. It must also be sustainable, and its success depends on people being actively engaged in designing the processes, mechanics, and methodology of innovation. To achieve this, we need a well-informed population, and that means patients, healthcare professionals, and commissioners working in concert.
Localising the work of the AAC, and by extension the LTP, means simplifying its aims and objectives into something that can be felt by local people and supported by local healthcare professionals. It means firing up the entire supply chain by putting patients at its start and not just at its end; it also means facing up to the significant workforce, landscape, and procurement challenges the NHS faces and making it relevant. More patients engage with healthcare via medicines than experience hospital in-patient stays, so we need to put medicine innovation at the heart of the transformation agenda.
The AAC has set three measures for its impact, which are:
- working with industry
- uptake of innovation
- value for the NHS.
In essence, the metric can be expressed as ‘has it made a difference?’ Locally, this needs to be evidenced by patients. Ask patients within specialised services who pays for their care and, largely, they will not know. However, they will know if it is making them feel better.
- HM Government. Accelerated access review: final report. London: HM Government, 2016. Available at: www.gov.uk/government/uploads/system/uploads/attachment_data/file/565072/AAR_final.pdf
- NHS England. The accelerated access collaborative. www.england.nhs.uk/ourwork/innovation/accel-access/ (accessed 2 September 2019).
- HM Government. NHS patients to get faster access to pioneering treatments. www.gov.uk/government/news/nhs-patients-to-get-faster-access-to-pioneering-treatments (accessed 2 September 2019).
- TheAHSNNetwork. Interview with Dr Sam Roberts, Chief Executive of the Accelerated Access Collaborative. www.ahsnnetwork.com/interview-dr-sam-roberts-chief-executive-accelerated-access-collaborative (accessed 2 September 2019).
- NHS. NHS Long Term Plan. www.longtermplan.nhs.uk (accessed 2 September 2019).
- NHS England. Specialised services. www.england.nhs.uk/commissioning/spec-services/ (accessed 2 September 2019).
- NHS England. Our 2017/18 annual report. NHS England, 2018. Available at: www.england.nhs.uk/wp-content/uploads/2018/07/Annual-Report-Full-201718.pdf
- HM Government. Faster access to treatment and new technology for 500,000 patients. www.gov.uk/government/news/faster-access-to-treatment-and-new-technology-for-500000-patients (accessed 2 September 2019).
- Griggs I. Pharma gears up for fresh market-access debate over new-wave cancer treatments. www.prweek.com/article/1588845/pharma-gears-fresh-market-access-debate-new-wave-cancer-treatments (accessed 2 September 2019).
- NHS England. NHS set to save record £300 million on the NHS’s highest drug spend. www.england.nhs.uk/2018/11/nhs-set-to-save-record-300-million-on-the-nhss-highest-drug-spend/ (accessed 2 September 2019).
- NHS. Working together. improvement.nhs.uk (accessed 2 September 2019).
- NHS England. Integrated care systems. www.england.nhs.uk/integratedcare/integrated-care-systems/ (accessed 2 September 2019).
- TheAHSNNetwork. Academic health science networks. www.ahsnnetwork.com/ (accessed 2 September 2019).
- HM Government. Social impact bonds. www.gov.uk/guidance/social-impact-bonds (accessed 2 September 2019).