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World class commissioning: 5 ways pharma can get involved

Published on 13/07/09 at 04:44pm

The NHS has set its sights unambiguously on achieving World Class Commissioning. After years of being internally-focused, the health service is now trying to benchmark its performance against other healthcare systems.

This ambition, first set out by the Department of Health in late 2007 is now one of the central ambitions for the health service, and an area pharma companies must understand and engage with.

But anyone who has ever watched England footballers' attempts to win major international trophies will know that the belief a 'world-class' level can be achieved can be shown to be hopelessly misplaced when the moment of truth arrives.

So the Department of Health's commitment that Primary Care Trusts will achieve World Class Commissioning (WCC) of services has created a formidable goal for the health service.

World Class Commissioning even has its own slogan, summing up its goal: "Adding life to years, and years to life" - but what does this mean in reality?

World Class Commissioning has three component elements: Outcomes, Competence and Governance.

Outcomes is the core objective of PCTs. In consultation with their local populations, local authorities and their boards PCTs decide on the 10-15 major outcomes for health that "add years to life and life to years."

PCTs should then have 10-12 competencies which characterise 'world class' commissioners and PCTs. Governance consists of very clear 3-5 year plans which produce health gains. They must have a clear operating plan for managing both organisation and workforce. PCT boards must demonstrate they understand these aims and are effectively directing the organisation.

Engaging with World Class Commissioning

So how does pharma engage with this agenda? One prerequisite is that companies must discard the tactics of yesteryear and develop more mature relationships with the NHS. This means applying the knowledge that today's customer is not an individual, but an organisation. PCTs have matured, become bigger and have assumed huge responsibilities. For pharma, this is a game-changer.

Success for marketers looking to work closely with the modern NHS will hinge on an ability to develop a wider range of skills. With a wide array of new stakeholders influencing the uptake of drugs, companies need to develop customised messages that resonate with each of their various customer groups. These messages must knit together to form an integrated market access strategy that shares one common goal, and is built from one common data source. As PCTs become increasingly sophisticated in what they are trying to achieve, the need for pharma to adopt an account management strategy has moved way beyond theory.

Understanding the commissioning function is central to engaging with the NHS, and will help companies play a role in delivering world-class performance. In its fullest sense, commissioning is not confined to commissioners - it applies to anyone within a PCT that is involved in the process, and that won't just be the person who writes the service specification, does the procurement or signs the contract. The whole executive management team within a PCT has a role to play. Customers involved in the commissioning function typically include:

* Directors of Public Health - responsible for determining strategy and prioritisation

* Directors of Finance - responsible for funding

* Heads of Medicines Management

* Chief Pharmacists

* Prescribing Advisers

* PBC Leads - normally a lead GP or PBC project manager

As you can see, the commissioning customer group is a broad group, underlining the fact that communication can no longer be a simple, linear process. It is in direct contrast to going out and detailing three products directly to a clinician, and as such requires a lot more sophistication.

Despite this, the fundamentals of commissioning are actually quite straightforward. In simple terms, there are two basic components: specification and implementation. Commissioning is about buying services. The process begins with identifying what is required, and, following purchase, concludes with its implementation. Individuals involved in the commissioning process in the broadest sense will therefore have a certain amount of these two functions within their role, with some heavily focused on specifying and others on implementation. The most high profile players, however, sit somewhere between the two.

So how can pharma companies engage with this initiative?

Five ways to engage with WCC

Broadly speaking, there are five common scenarios for engagement between pharmaceutical companies and the commissioning function. These are:

1. Prioritisation

2. Replacement therapy

3. Service redesign

4. New therapy and service redesign

5. PBC - a special case

Each scenario will occur at different stages of the commissioning cycle, will involve different customers and require a different approach.

1. Prioritisation: Prioritisation is the preserve of the senior management team within each PCT. These teams are increasingly being charged with taking national policy - the top-line targets that must be achieved - and identifying the health challenges that are most applicable to their local economy. This, in turn, drives a wish-list of priorities around which the PCT will expect services to be commissioned. For the marketer, this is critical information that will dictate your approach. For example, if you've got a product for COPD and a particular PCT has not prioritised it, don't bother trying to engage them. They won't want to know.

Pharma does, in fact, have an opportunity to engage with commissioners at the prioritisation stage and to influence decision-making. PCTs need good, evidence-based information to help them reach their decisions. If, for example, as a marketer in COPD you can demonstrate that the disease is being poorly managed, leading to emergency admissions and high costs that could be reduced by a better focus on prevention, this is the kind of information which these customers want. Better still, if you can show that by investing in a primary care prevention programme and educating GPs, you may be able to convince them that the disease can not only be managed more efficiently before patients suffer an emergency exacerbation requiring an ambulance, but also that there is potential to save money and reduce hospital waiting lists.

Most PCTs have a planning cycle which will begin with prioritisation. This normally starts in September and, if you miss this, it can be a real challenge to get back in.

2. Replacement Therapy: A replacement therapy effectively relies upon a clinical sale. The key commissioning customer here will most likely be the prescribing adviser, who will have a major influence on both the specification and implementation process. Alongside them, public health clinicians will have a lesser, though not insignificant, role, largely focusing on specification.

In the case of replacement therapies, key messages will normally state that the new drug is better than the current option, but their uptake won't drastically affect the way a service is delivered. Equally, the product may not have huge implications for patients. If there are implications around cost, you will need to present an argument to demonstrate the benefits of this extra cost. As a result, economic data becomes critical. Having data that shows your drug is clinically better is no longer good enough. PCTs have gone past the stage where they pay for something simply because it is better - they want to know how much better it is, what they need to spend to get that improvement and what that improvement will really mean. Crucially, they want evidence that the improvement gives them an outcome that interests them.

The traditional imperatives of proving clinical safety and efficacy remain a pre-requisite - and you won't get to the table without them - but to get beyond that, you have to have something more. In modern football, the most valuable players don't just score the goals, they track back and defend where necessary. And their marketability rockets.

3. Service Redesign: This aspect is far more complex because, by definition, it means that what you are proposing creates a need to redesign an existing service. Consequently, service redesign involves the full range of commissioning customers. Each payor group will require a different set of messages and information in order to make it happen. In this scenario, Public Health clinicians will play a pivotal role in the specification aspects, while PCT/PBC project managers will be highly significant in the implementation. In addition, prescribing advisers and strategy leads will also be influential and require their own customised approach.

Industry understanding of service redesign has improved dramatically in the past couple of years, with greater recognition of it as an opportunity. However, pharma's ability to engage in the process still has some way to go. So when and why might you consider service redesign? Generally speaking, service redesign follows a recognition that an existing service is not delivering the required outcomes.

Once again, COPD provides a useful example. Despite the fact that there are very good drugs available to treat COPD, hospital admissions due to the disease continue to rise simply because the services are not good enough. In fact, the care pathway for COPD is very well defined. The problem is the prevention versus cure argument. The NHS has been set up to cure people - you have to get ill before there's an intervention - and this doesn't work well with chronic diseases. The more modern approach is to prevent disease, and COPD is a classic example. So instead of catching people in an ambulance and having to intervene in a complex way, you set up a service to identify people earlier, educate them and get them to look after themselves more effectively. The same applies in diabetes - by doing a retinopathy diabetic screening and ensuring patients manage their insulin better, there is a reduced likelihood of them developing foot ulcers and going blind.

Clearly, in the new environment, service redesign has taken on huge importance. But how do you engage with it? Service redesign provides perhaps the clearest example of how new and traditional approaches need to combine in a coherent market access strategy. The industry still needs to have its clinical studies and data to get a place at the table. But it also needs to have outcomes data to support it. Just like any marketing exercise, you will need Continued over good phase III clinical data and the support of clinical key opinion leaders. But you will also need evidence of health outcomes, patient experiences and, critically, a different kind of opinion leader from the commissioning community. From here, you develop your key messages.

These messages aren't that your product is safe and 10% better than the competition. It has to yield an outcome that matches with the goals of the local PCT. Does it stop people going into hospital? Can it be delivered in the community, nearer to patients' homes, and does it save the NHS money? In an era where the patient experience is becoming more and more important, you need to have evidence that your patients like your product. In a few years' time, we may well have reached the Whiskas model of NHS service provision: If 8 out of 10 patients say they prefer the COPD service you helped design, every PCT in the country will want to follow that model.

4. New therapy with service redesign: This model follows the same principle but is even more complex - you need to throw in a clinical sale with the redesign. In isolation, the two aspects are straightforward. In combination, the challenges are greater. In service redesign, the main battle, whether a replacement therapy or a new product, is to avoid linking the product to the service. From the perspective of the ABPI Code, it is not possible to perform the clinical sale and propose the redesign within the same dialogue.

In this model, prescribing advisers, project managers, public health clinicians and strategy leads each play a hugely influential role. Their information needs, however, all differ significantly.

5. PBC - a special case: The PBC agenda for commissioning is not always the same as a PCT one. As organisations, they occasionally try to do different things. In some ways, a PBC is a more clinical organisation because it is led by GPs - as such, their motivation can often be less about top-line targets and more about doing good for their patients. Although they may be working in the same direction as a PCT, they may also have different objectives and perspectives. For example, both PBC practitioners and PCTs may have a shared goal in improving diabetes care, the PCT commissioner may seek to move care out of hospitals and save money, while the PBC may simply want to improve services to improve health outcomes for their specific patients. So long as both organisations are moving in the same direction as you design a service, there is no issue. But there is potential for conflict where objectives fail to match.

In this scenario, the strategy lead (often a GP) will play a major role in both the specification and implementation of PBC-led projects. In addition, the project manager will be hugely influential in the implementation aspects, while prescribing advisers will play a crucial supporting role.

The right customer at the right time

In each of the scenarios outlined above, the success of the engagement will hinge on pharma's ability to provide the right information to the right customer at the right time. This philosophy sits at the heart of a robust market access strategy. Commissioners and payor-groups require different messsages to satisfy their individual requirements. These manifest themselves in a variety of information products which commissioners seek and, ultimately, pharma needs to provide.

Nowadays, the types of information required depends on which customer you are speaking to. Information needs are around health need, population prevalence and the burden of disease. Considerations will include what the resource utilisation is, what changes will be required when you bring your new drug in, what the acquisition costs are and what the savings might be.

Likewise, how well are the patients likely to be involved and what are the complications of service redesign? Clearly, the type of information currency you will need will depend on the scenario and the customer with whom you are engaging. In every case, the key messages you will need to communicate will be different.

The key for marketers is to become more customer-focused. You can't rely on the simple, linear approach that has worked in the past. The market is too complex, there are too many barriers and too many stakeholders.

The real challenge is how to create market access for your product. Success depends upon understanding that your customer is now an organisation, and that there is a range of stakeholders you need to approach with the most appropriate currencies and messages.

The battle is to understand your customers and their objectives. And then give them the information they need in order to help them achieve them. You can't expect to purchase market access for your product unless you talk to customers and give them the right currency. In that respect, it's very simple.

And so, the message for pharma as we move into the new era of World Class Commissioning, is to understand the need to develop and implement a new, expansive style of play. Old tactics will no longer work. A more sophisticated approach is required. If you can get it right, you may just find you achieve your goal and, in the process, help your customers and their patients achieve theirs.


Outcomes: PCTs must identify 10-15 major outcomes for health that "add years to life and life to years" for their local population

Competencies: 10-12 competencies which characterise World Class Commissioners and PCTs

Governance: Clear 3-5 year plans focused on health gains for the local population. PCTs must have a very clear plan for managing their organisation and workforce, and PCT boards must demonstrate they understand these aims and show they are effectively directing the organisation.

Andy Lee is partnerships and commissioning director, WG Consulting. Tel:01494 470760 or email

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