New assessment tool heralds breakthrough for healthcare service redesign

30 January 2009

Health economics is often seen as a blunt instrument that tends to work against patient needs. As the desire to control healthcare budgets becomes ever more pressing, can a new kind of assessment technology help service commissioners find the Holy Grail of health provision — delivering cost savings and the best patient outcomes?

Health economics has become the watchword for healthcare provision across Europe in recent years. As the world faces up to recession, the importance of applying health economics to service redesign is set to intensify. To those expected to deliver healthcare and those hoping to receive it, this will probably be perceived as a worrying development because health economics is frequently seen as a method that tends to subjugate patient outcomes to meeting budgetary targets.

A plan by an English primary care trust (PCT) to introduce bonus payments to GPs for not referring patients to hospital recently caused uproar amongst patient groups who branded the idea as ridiculous and detrimental to patient care. But whilst opponents were focussing on the wisdom — and the ethics — of such a scheme, the fundamental importance of ensuring patients get the most appropriate treatment whilst reducing unnecessary and often expensive hospital referrals for those patients, was hardly mentioned.

However, these latter objectives are actually at the heart of the English primary care budgetary system called Practice Base Commissioning (PBC) which came into force in April 2005.

PBC is a process which offers large medical practices or groups of practices the opportunity to take control of elements of the commissioning budget for their patient populations. If these groups of practices manage to design and implement more cost effective services then they get to keep up to 70% of those savings to spend on behalf of their patients.

In general PBC encourages the avoidance of hospital-based procedures (where appropriate), not only because they are disproportionately expensive but also because they may not necessarily be the best way to deliver treatment to a patient.

Although PBC has strong political support, as yet probably no more than 20% of English practices are currently involved in service redesign. However, the Darzi Report, published in June of last year and commissioned by the UK Government to provide strategic direction for the English NHS, re-emphasises the role and importance of PBC for the future of primary care.

Pharmaceutical companies have quickly come to realise that in order to be part of PBC and interact meaningfully with locality commissioning groups they will need to develop novel resources that can aid the service redesign process.

One company in particular, LEO Pharma, has harnessed innovative technology to partner PCTs and practice groups in service redesign in the field of dermatology. It has developed a ground-breaking computer-modelling tool to help those involved in the assessment, planning and provision of psoriasis treatment in primary care make cost savings and, at the same time, improve patient outcomes.

Called Psoriasis and Me, the computerised resource was developed as a result of submitting a Health Technology Assessment (HTA) to the Scottish Medicines Consortium for one of the company’s most advanced products. It simulates the impact over two years of the use of a range of topical psoriasis therapies on patient outcomes and costs in a given primary care setting.

The programme works by comparing specific local data inputs — such as population size, waiting times for referrals to secondary care and the types and costs of treatments currently in use — to stored country-specific information and the Psoriasis Area and Severity Index (PASI 75). It then generates a report which calculates the optimum financial savings that could be made in a service redesign which would also improve patient outcomes using the most effective treatments.

Co-developed in the UK by LEO Pharma and specialist health economics and outcomes research company Amygdala Ltd, Psoriasis and Me has been piloted with English service providers for the past twelve months and has already received a glowing endorsement from the UK’s National Association of Primary Care (NAPC): “We commend this resource to commissioners and providers in primary care. The tool evaluates the most appropriate management of psoriasis within primary care as well as current service effectiveness where costs can be significant but, historically, have not been subject to detailed cost analysis.

“In NAPC’s view, one of the real advantages of Psoriasis and Me is that it helps clinicians ensure that people with psoriasis receive the right treatment at the right time and that patients are only referred to scarce specialist care when necessary. Such a tool supports PCTs, PBC consortia and practices both in commissioning and providing. Another potential beneficiary of the resource would be the new Integrated Care Organisations, when they have been approved by the Department of Health.”

The programme has also received extremely positive feedback from clinicians who have seen it in operation with actual patient populations. Keith Freeman, a UK Consultant Dermatologist with dual responsibility for services in a primary care trust and a foundation hospital trust in the North-East of England, sees the programme as a very welcome and valuable aid for local decision making.

He said, “The priority for service commissioners in treating psoriasis is to achieve the best pathways of care — to make sure that the right patients are being treated in the right place at the right time for the best possible outcomes. Treating effectively in primary care is better for the patient — not so stressful, less disruption to their normal life and no lengthy journeys — and also means secondary care resources can be focused on the most appropriate cases. Reviews help to encourage positive discussion which may not have happened before. Tools like this are the way forward to help clinicians review services, optimise care and keep better control of costs.”

The Psoriasis and Me pilot has also revealed the extent to which healthcare providers in England were unaware of the sizeable sums being spent on treating psoriasis and the extent of early and expensive hospital referral. In Keith Freeman’s area of operation, the number of first outpatient referrals for skin problems exceeds referrals for all other non-surgical medical conditions and he acknowledges the need for major change. “In the recent past dermatologists were mainly hospital-based so had a tendency to want to bring patients in for treatment and there was very little communication with primary care. Things are now moving; there is more discussion and a more patient-centric approach which looks at the patient’s needs first and foremost. However we still need better tools to help us deliver that approach whilst keeping budgets in mind and this is definitely a good tool.”

As a result of its unique way of comparing the outcomes of alternative treatment options to an existing regime, Psoriasis and Me has also shown service commissioners a strong opportunity to make significant savings in their budgets which could run into millions of pounds if replicated across the entire country.

“The programme has already shown that as a result of more effective prescribing for psoriasis in an English primary care population of, say, 250,000, yearly savings could be as high as £277,000,” said Peter Jackson, Commercial Development Manager for LEO Pharma UK, who has been working on the Psoriasis and Me project from the start. “If you extrapolate that kind of result to the UK population as a whole (c60million people), the potential annual saving could be as much as £66million. And with the current pressures on healthcare budgets that’s the kind of saving that’s hard to ignore.”

LEO Pharma is apparently now working with Amygdala to develop the programme for use in psoriasis management in a number of Northern European countries, with a potential roll-out in the next two years.

The involvement of information technology in healthcare management has recently had some unfortunate set-backs, as systems fail to live up to expectations or just fail altogether. However, this development offers a much more positive prospect to those involved with healthcare commissioning and planning. Indeed, the implications of the development of such a sophisticated assessment tool go way beyond improved care for psoriasis patients; they seem to offer healthcare providers the very real prospect of a way to reconcile the previously divergent goals of minimising cost and maximising patient outcome in service redesign.

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