Understanding system mechanics can help your pitch succeed

The UK healthcare system is confusing, there can be no doubt about it. It’s huge, constantly changing, and full of concepts that appear designed to bewilder. I’ve talked at length about System, Place and Network and people from the Pharma, MedTech and Devices regularly ask me what those terms mean.

And there’s other questions around that – what if a practice doesn’t want to be part of a network, for example? What happens to its patients? And what happens to the practices that do want to be part of a network, but the network doesn’t want them?

It’s always useful to recap these terms. Even a basic understanding of them helps the industry get to grips with its audience and ultimately make pitches and conversations easier and more likely to succeed.

System, place, network

System is the whole integrated care system footprint and that’s usually around a million people upwards. The biggest one I’m aware of is North West London which has around 4.2million people, but the majority of those I work with have a rough population of 1 million.

Place is the local authority footprint. Some place areas are small – Rutland in Leicestershire is a good example of that. It’s a unitary authority in its own right, covering just 40,000 patients as part of a system of more than a million patients. That system has two additional places – the city of Leicester and the County.

And then down below that we have the make-up of the Primary Care Networks. These are based on the registered list of the general practices that are members of the network. They were designed to be geographically linked groups of 30,000 to 50,000 patients but last time I checked the 1307 networks that existed at that point, the average size of a network was around 60,000.

That’s because there are a number of bigger networks pushing the average up. One I work with is 120,000 and another is 73,000. All, as I say, built from the registered list population of the member practices.

Building one coherent voice

So let’s start with one of the customers I work with, Leicester, Leicestershire and Rutland. Here, we have 133 general practices that make up 26 primary care networks. From there at place level, some of those networks – may be four or five – come together and have the support of a GP Federation. The federation supports them to join forces, collaborate and manage contract requirements, the money, the investment and impact fund, additional roles, staff they are recruiting etc, there’s lots of benefits to working in that way.

And then above that we have a Place Federation. So if you look at the west of the county, there are a number of network federations, and then a Place Federation that brings together the view of the west of the county. It’s the same system in the east of the county and they are also looking to replicate it in the city.

The Place Federation then connects into what they call locally the Partnership Board. On there sits representation from right across the networks and the whole of the Integrated Care System from General Practice. They then connect into the System Federation – all 133 practices are members of that – and then that connects into the Integrated Care System.

As we can see from our graphic, it’s a busy, complex structure. But that’s because we have to get from 133 practices down to a single strong, coherent voice for general practice within the system – a voice that is actually heard.

Challenge of increasing hours

This way of working has been replicated right across the country. It’s vital that General Practice has a voice because without it, systems tend to make decisions. And then everybody else is left picking up the pieces because they’ve not been able to express a view.

And even though it seems to be a busy and complex way of doing things, it’s actually pretty straightforward because the networks do what they need to do, the network federations do what they need to do and they then start to represent the view up into the system.

In Leicester, Leicestershire and Rutland, there is no practice that isn’t part of a network and there is no practice that wants to be part of a network that isn’t. But if we did have a practice that suddenly said ‘We don’t want to be part of a network’, the Integrated Care System – or as it stands at the moment the Clinical Commissioning Groups because they are still the statutory bodies – will work with the local networks to agree which one is going to take the patient population for that practice.

And that’s because those patients have got to have access to all the network services. As an example, Primary Care Networks have got to deliver extended hours access.

Right now, PCNs and/or Practices have to offer 30 minutes of Additional Hours, per 1000 patients, either before 08.00 in the morning or after 18.30 at night, or at the weekend. Most Practices simply deliver this for their own patients and pick a time that suits them, but there is a significant change coming, where the PCN will have to offer 60 minutes per 1000 patients and PCNs must now deliver 18.30 to 20.00 Monday to Friday and 09.00 to 17.00 on a Saturday (or Sunday if the population prefer this) for the whole population of the PCN. The caveat I will give you is that we are still waiting on the final specification, so things remain fluid until we get that.

It’s not viable on the money available to open all practices, meaning many PCNs are now thinking about how they handle this by developing a hub to operate for the PCN patients. And that will be the topic of a separate blog because it will present some brilliant opportunities for the industry.

What are the networks concentrating on now?

Apart from Extended Hours, other items on the list of things the Primary Care Networks must deliver include:

• Structured medicine review and optimisation.
• Enhanced health in care homes.
• Early cancer diagnosis.
• Social prescribing services.
• Cardiovascular disease (CVD) diagnosis and prevention. There’s a big opportunity in there for Pharma, MedTech and Devices because that’s around hypertension, familial hypercholesterolemia, heart failure and atrial fibrillation.
• And tackling neighbourhood health inequalities, which I’ve talked about in a previous blog.

They also have the Investment and Impact Fund (IIF) and the indicators within that, but that’s optional. I’ll talk more about the IIF more in a separate blog about the CVD prevention opportunities.[JF1] 

So those points above are what they’re working on right now. The goal is that the commissioner ensures complete coverage of the entire patient population. So if a practice didn’t want to join, the population is added to the network and then has access to all those network services.

If you’ve got a practice that wants to be part of a network but there isn’t a local network willing to accept it, that then gets passed back to CCG (as it stands now, Integrated Care System in the future). Lots of behind-the-scenes negotiations go on to try to find the network to take them.

If that fails, there is a forced allocation. The CCG says: “That’s the network you’re going into.” That can be fraught with risk and danger that the network then ceases to function properly, but that’s the rule. It guarantees that everyone who wants to be part of a network can be and all the services required to be delivered to the population are available to them.

Get to grips with their agenda and you’ve cracked the system

So the key from an industry perspective is that once you understand this, you then start to understand who the key people are at each level – Network, Place and System.

That gives you the opportunity to work out the real problem that you solve. So is it going to be that you can reduce appointments in the practices because you improve patient outcomes? Can you reduce referrals or admissions? Can you help to close the inequalities gap? There’s lots of agendas you can engage with and you can play on.

The key is understanding what agenda they’re working on, how you can align with it and help them work. This is way beyond talking to them about an individual product. This is talking to them about the problems they have, which are generally way too much work and not enough people to meet the demand they’ll be asked to deliver.

They will therefore have a desire to innovate and work in a different way – and that’s where you come in.

Scott McKenzie helps pharmaceutical, medical technology and device firms increase revenue by getting their products and services in front of the right NHS decision makers. If you want to get your products fully embedded into treatment pathways we can help you. We’ve doubled revenue for our clients and can share these processes with you too. If you want to improve the way you sell to the NHS you can watch our free webinar here.