The Medical Technology Group (MTG) is a UK coalition of patient groups, research charities and medical device companies working together to improve access to medical technologies for patients.

The Group benefits from a wealth of experience in working with the NHS and associated bodies to promote access to medical technologies for patients. The Group wishes to ensure that the patient voice is heard in the conversation about the NHS backlog and waiting times worsened by COVID-19, and that positive changes seen during the pandemic are taken forward to ensure benefit to patients in the future.

Inquiry Details

The Health and Social Care Committee has launched a new inquiry to consider how Integrated Care Systems (ICSs) will deliver joined up health and care services to meet the needs of local populations.

Forty-two new ICSs were established with a statutory footing across England on 1 July.

Integrated Care Boards (ICBs), one element of an ICS, will hold budgetary responsibility with duties around service improvements, reducing inequalities, promoting innovation and patient choice and will take on many roles of Clinical Commissioning Groups (CCGs). Integrated Care Partnerships (ICPs) will work with local authorities and will be responsible for producing an integrated care strategy.

Among areas to be considered, are how ICSs will be able to operate with the flexibility and autonomy required to tackle inequalities in the populations they serve and whether the pursuit of central targets can be consistent with local autonomy.

Inquiry Response

1)      How best can a balance be struck between allowing ICSs the flexibility and autonomy they need to achieve their statutory duties, and holding them to account for doing so?

The Medical Technology Group (MTG) agrees with the overall vision for accountability within Integrated Care Services, particularly in ensuring there is ‘excellent value, good outcomes and improved experience for people’.

Patients should have access to the necessary treatment, regardless of where they live and ICSs should have the flexibility to meet the regional specific needs of the population. However, there needs to be sufficient accountability structures within an ICS to ensure that patients have access to all necessary treatments, including approved innovation and technology; and that there should be appeal mechanisms put in place for when that treatment is not made available to them.

There should be clarity on what mechanisms are available to sufficiently hold ICSs to account, particularly in the early phases of ICS implementation. There needs to be national accountability for decisions made by ICSs which restrict patient access to treatments and technologies.

The MTG also has concerns about accountability for specialised commissioning within the ICS structures, and the risk of regional variation in the commissioning of services leading to further disparities within the health and social care setting.

2)      What does a permissive framework for ICSs look like in practice?

The MTG believes ICSs should have a permissive framework that supports innovation and improvement. Where regional health targets and priorities change, frameworks should vary, allowing ICSs to adapt and promote innovation and improvement.

Alongside the necessary variation to ensure local health targets are given sufficient attention, the MTG believes some aspects of an ICSs framework must be consistent nationally to ensure positive outcomes for patients. These include responsibilities over:

• Patient voice and involvement, for example, patient representation at every level of ICS decision-making, including at ICB and ICP level.

• Specialised Commissioning, including clarity around:
• budget for specialised commissioning at ICS level
• changes to the pathway for patients to access specialised treatment
• how ICSs will work individually and regionally to deliver treatments

• Regional variation, with safeguards to ensure that services do not become fragmented and there is accountability for delivery of services

• Accountability, ensuring that:
• ICSs are held to account, adhering to national guidance and ensuring patient access to treatments
• there is a mechanism to challenge ICSs if they restrict patient access to approved medical technology
• there are mechanisms in place to hold ICSs to account at a local and national level

3)      Are central targets consistent with local autonomy in this context?

The MTG believes a local approach to health delivery has positive indications for patient outcomes. The setting of local priorities and targets must be appreciated as a vital benefit of the move towards ICSs, and this must not be clouded with too much central oversight.

However, the MTG does agree with centrally set indicators and targets over overarching and patient-orientated objectives. While condition-specific targets over the issues affecting local populations should be led by ICSs, targets and priorities over patient safety, positive outcomes and readmission rates should be determined centrally, with necessary incentives put in place to support these.

The MTG agrees that functions retained by NHS England should include:

• responsibility for some specialised services that need to be centrally commissioned
• identifying national priorities, setting outcomes, and developing national contracts or contractual frameworks
• maintaining national policies and guidance that will support ICBs to be effective in their delegated functions

4)      To what extent is there a risk that ICBs become an additional layer of bureaucracy if central targets are not reduced as ICBs are set up?

The MTG believes that a joined-up health system that removes organisational barriers between different care settings can greatly benefit the patient.

MTG is pleased with the move towards collaborative working, and that local authorities will be aligning with NHS policy areas to tackle the biggest healthcare challenges faced by communities, such as improving cancer care and reducing health inequalities. ICSs will be in a positive position to work towards the objectives in the NHS Long Term Plan and NHS Elective Backlog Plan.

However, the MTG is concerned about the lack of vision for integrating the patient voice in the arrangements for integrated care, which should be an integral part of the shift from centralised targets to ICBs. As a dedicated coalition of industry and patients, the MTG works to put the patient voice at the heart of conversations about the UK’s health service.

The group believes that plans fall short of ensuring that patients have a clear role to play as partners and/or decision-makers in a future system of integrated care. Whilst decisions will be taken ‘closer to communities’ there is no indication whether these are patient communities or local populations and why such decisions cannot be taken ‘with’ communities. Plans should be reviewed with the objective of placing the patient at the heart of the decision-making process and far greater emphasis should be placed on co-production.

The MTG believes the patient voice should be mandated in decision making processes and on ICS boards. Prioritisation decisions will need to be made to address the backlog post-covid. However, patients are those who are most affected and must be brought into the decision-making process regarding prioritisation.

The MTG agrees there is a risk that ICBs could become an additional layer of bureaucracy, however, where necessary, patient safety must be prioritised.

5)      What can be learned from examples of existing good practice in established ICSs?

In 2021 the MTG relaunched its successful Ration Watch Campaign. The aim of Ration Watch is to shine a light on areas in the Health and Social Care system where there is regional variation in the NHS’s success in clearing the elective backlog and reducing the waiting lists.

In 2022, the MTG is focusing on regional variation in the number of patient procedures performed. This work compares the data on 4 key clinical areas across each NHS region, looking for consistency of services across a CCG. The MTG has mapped NHS England’s Consultant-led Referral to Treatment Waiting Times Data, focusing on the complete pathways within the following treatment areas:

•           Cardiology
•           Gynaecology
•           General Surgery
•           Trauma and Orthopaedics

As part of this work, the MTG has looked to build case studies of good practice. These case studies are being compiled through the MTG’s wider membership and meetings with NHS organisations to discuss examples of best practice, for example, Wakefield Clinical Commissioning Group (CCG) and Northumberland Clinical Commissioning Group.

Good practice is evident within established ICSs, whether through improved referral pathways, rapid technology uptake or moves towards digital health solutions. However, it is clear that no formal mechanism exists for this to be shared nationally.

Vital learnings can be taken from existing good practice, however, there must be a formal structure for these to be shared nationwide, and not be reliant on informal discussion. It is imperative that NHS organisations are given the information and tools necessary to tackle their elective backlogs.

There is a clear need – based on the success of some of the innovations highlighted in the MTG’s work - to promote the use of proven technology and ensure fair access for all patients. The benefits of technology include:

• Giving patients more choice and control over treatment
• Streamlining pathways by reducing complications and readmissions
• Reducing the pressure on the workforce by improving efficiencies and reducing time and money spent on administration through digital health solutions
• Better outcomes for patients through minimally invasive alternatives to treatment
• Improved training programmes for HCPs, ensuring technology is used safely and effectively
• Long-term financial savings by increasing efficiencies and reducing long-term dependencies on the health system

Tackling the backlog will also require collaboration and working across natural boundaries and borders to tackle common challenges. This has been demonstrated most acutely through provider collaboratives, where providers have worked together to tackle waiting lists and common challenges. This is a key tool in the fight against the backlog, and one which may be used increasingly as the ICS system embeds, and collaboration across areas is promoted.

6)      What scope is there for variation between ICSs, to enable them to improve the overall health of the populations they serve and tackle inequalities?

It is clear from looking at NHS England’s Referral to Treatment data that a patient’s ability to access care varies depending on where they live, a conclusion laid out in the MTG’s soon to be published 2022 Ration Watch Report, Tackling Regional Variation in Healthcare:  Inequalities, Innovation, and Integration.

The potential impact of ICSs is not yet known, however, from the variation in the outcomes from CCGs, each ICS will inherit a wide spectrum of quality of practice, with very different patient outcomes. How ICSs deliver for their patients will depend on whether the best models of care from their component CCGs can be used as exemplars to bring the performance up of the poorest performing CCGs.

Regional health inequalities may be a determining factor on the performance of an ICS when looking at the number of particular health conditions and the associated complications, for example, obesity or diabetes. Through the transition from CCGs to ICSs, and the subsequent shift to internal structures, many commissioners will see a change in how they are seen to perform nationally, while also gaining an ability to better address issues affecting their populations.

A number of CCGs integrated their services throughout 2021 while maintaining the old CCG model, for example, South West and South East London. In comparison, others such as the Greater Manchester Health and Social Care Partnership, will be integrating the 10 component CCGs for the first time in July 2022.

There is variation across every ICS that did not integrate services prior to March 2022. According to MTG analysis, in the Greater Manchester Health and Social Care Partnership, the completed pathway rankings of the component CCGs range from 7th to 92nd, in the Cheshire and Merseyside Health and Care Partnership, 2nd to 93rd and in Sussex ICS, 15th to 82nd.

It is clear that some ICSs will include CCGs that skew the data through better or worse performance, meaning the measure of their overall output may appear higher or lower than it could have been otherwise, due to those anomalous CCGs. It is in cases such as this where ICSs must drive local performance up to the standard of their best performing, opposed to down to their worst. In the West Yorkshire and Harrogate ICS, this will mean making an effort to improve all services to meet the output of Wakefield (1st), rather than down to Leeds (83rd) or Bradford District and Craven (77th).

According to the MTG’s analysis, in March 2022, patients in London-based ICSs were far less likely to have their pathways completed than patients based in the South West, North West or North East. In March, 5.24 pathways were completed in the North East (per 1000 of the population), 1.44 more than in London.

Variation in care will still be evident in the move to Integrated Care Systems. However, by bringing more patients under single bodies with additional control, there is the opportunity to make use of centralised decision-making, for ICSs to share best practice and implement positive change.

7)      How can it be ensured that quality and safety of care are at the heart of ICB priorities?

The new model of care provides a greater incentive for collaboration. As a minimum, it is right that representatives from commissioners; acute, community and primary care providers; and local authorities are responsible for delivering local models of integrated care.

However, the MTG believes that the proposals do not adequately outline NHSE’s role in delivery and maintenance of adequate healthcare provision for patients.

There is a lack of information around whether patient data reporting will be managed centrally or locally. NHS England, the Department of Health and Social Care and ICBs must be in a position to ensure that patient data is recorded and analysed to ensure that necessary steps are being taken by ICBs to achieve the best outcomes for patients.

Furthermore, there is a lack of clarity around what role NHSE will play in providing minimum specifications for the delivery of services. Whilst the MTG agrees that local accountability and priority setting will be essential to this system, NHSE should clarify whether a minimum service specification will be set out centrally for routine treatments. The MTG raises that patients should be entitled to know how long they should be waiting for a routine treatment and that this shouldn’t vary depending on locality.

The MTG further believes that there should be clarity over the future of local and national targets. It is unclear as to whether the 18 Week Referral to Treatment Target will continue to be monitored by NHSE and Trusts judged by their standards of delivery in this area. If these targets are to be removed, then NHSE should set out clear plans for how ICSs will be incentivised to meet defined standards and tracked on the delivery of timely patient access to healthcare. Particularly given the backlog of elective produces caused by COVID-19, it is essential that system targets are measurable and achievable.

Separately, the MTG would also like to note that whilst there is a commitment to maintaining patient choice of treatment provider, there is very little detail as to how this will operate in practice. Patients should be able to make an informed choice about the best treatment for them and healthcare professionals should be in a position to advise patients of treatments available in other localities. ICBSs should outline what steps will be taken to ensure that patients can access appropriate treatments outside their locality.

As mentioned, the MTG is also concerned about the lack of vision for integrating patient voices over the quality and safety of care in the new arrangements for integrated care.

The group believes that patient representatives should have a clear role to play as partners and/or decision-makers in a future system of integrated care, and that there should be a patient representative at every stage of ICS decision making. Again, plans should be reviewed with the objective of placing the patient at the heart of the decision-making process and far greater emphasis should be placed on co-production.

8)      How best can this be done in a way that is consistent with how providers are inspected for safety and quality of care?

The MTG believes that the patient voice can play a large part in providing consistency across the safety and quality of care at ICS level.

The MTG believes patient involvement should be mandated in decision making processes and on ICBs.

Prioritisation decisions will need to be made at ICS level to address the backlog post covid. However, patients are those who are most affected and must be brought into the decision-making process regarding prioritisation and the commissioning of care.

It is impossible to capture the full benefits or qualities of any service without understanding the full benefit or impact to the people using it. Health economic assessments, whilst necessary and valid, will always struggle to understand the full benefit to patients.

Decision making processes should include patients who have received access to a relevant treatment or service. Decision making processes need to be established at the start of any process, and this should include a clear role for patients. Where assessment panels are convened, patients should be included and given the same weight of voice as any other member of the panel.

Too often the patient voice is marginalised, with patients being allowed to consult rather than make a direct impact on the final decisions on the use of technology. The MTG would see patients placed at the heart of decision making with a clear and defined role in the process.

9)      How can a focus on prevention within ICSs be ensured and maintained alongside wider pressures, such as workforce challenges and the electives backlog?

The MTG would like to note on record that access to medical technology is central to the delivery of integrated care and prevention, particularly for patients with long term conditions.

Around the UK, too many people are experiencing undue delays accessing healthcare, being diagnosed too late and spending too many years in poor health. Most worryingly, these burdens are not felt equally across society.

Much of ill health can be prevented, and the Long-Term Plan sets out the NHS’s commitment to move towards a prevention and early-diagnosis model. With the current pressures on the NHS, combined with the backlog and workforce challenges, keeping people healthy and out of hospital has never been more important.

Medical technologies will be at the heart of delivering this agenda and rebalancing healthcare delivery away from chronic and acute intervention and towards prevention and early intervention. This focus will significantly reduce pressure on other NHS services, where more significant interventions are required. Use of valuable medical technology and a focus on diagnostics can result in fewer or shorter admissions to hospital, reducing the burden to hospitals of unplanned admissions and making beds available for other patients, save lives, and reduce pressure on the NHS by reducing the need for late stage, expensive and time-consuming interventions.

Medical technology can provide a range of support in this area:

• Diagnostic technology can help the NHS to detect and diagnose conditions early and offer patients the opportunity to take preventative measures and stop the worsening of conditions.
• Remote monitoring allows patients to be monitored and flagged when in need of treatment, removing timely and costly outpatient appointments for assessment.
• Artificial Intelligence and digital health solutions can remove burden from consultants and administration staff when looking to the organisation of a patients pathway, while also contributing to remote monitoring.
• The use of minimally invasive treatment and day case procedures facilitated by medical technology can reduce bed use in hospitals and speed up patient throughput which can help address the backlog of care in the NHS. 

The increased investment in community diagnostic centres, announced in the recent Spending Review, and the associated funding is welcomed. However, the NHS now needs to work effectively with these hubs to ensure a smooth pathway for patients, and that people can be seen in a timely and efficient manner.

Medical technology can offer the support patients need by empowering them in their decisions on how to best manage their conditions, and supporting community and primary care settings, which support patients in doing so. As such, medical technology plays a key role in supporting the NHS’ vision to integrate and personalise care.

The earlier issues are picked up by individuals or clinical professionals, the more effectively they can be treated. Encouraging checks whenever an individual is within a healthcare setting is an opportunity to pick up on undiagnosed conditions at a time convenient to the patient and healthcare professional. Intelligent screening is also linked to this focus on early diagnosis and is key to improving patient outcomes.

Aug 2022