Managing medical education

pharmafile | February 3, 2004 | Feature | |   

Over the years, Medical Education (med ed) and PR agencies have been an invaluable part of the marketing mix. Med ed has helped position and distinguish many a new product within the existing treatment options and educate doctors into the use of new chemical entities, their mode of action and rationale within a therapy area. Meanwhile it is customary to use PR agencies to set up advisory panels to discuss and develop product strategies as well as endorse products post launch from the clinical perspective.

However, brand managers, healthcare development managers and other sales and marketing colleagues must recognise not only has the need for national PR now changed, but that traditional med ed is no longer sufficient in the modern NHS.

The need for medical management education

What do GP appraisals, the National Primary Care Development Team (NPDT), preventative measures in primary and secondary health, the new GMS contract, NICE and the commissioning of services all have in common? They all involve proactive management of chronic diseases, which in turn requires effective medical management education.

To show why chronic disease management is so important and why it requires effective medical management education we asked a number of leading NHS clinicians, managers and academics on Medical Management Services Professional Partnership Board.

The World Health Organisation predicts that by 2020 it will be the largest global cause of disability. Almost nine million people in England suffer from a chronic disease – 40% have more than one condition.

Professor David Colin-Thome, GP and national clinical director for primary care, Department of Health, highlights the management of chronic diseases as one of the most important health issues of the 21st century. "Chronic disease accounts for 60% of GP consultations and is a factor in an equal number of hospital admissions," he said. "Developing systems of care incorporating patient self-management is the only way to improve the management of chronic illness. Medical management education is central to its success as systems belong to management."

Appraising management processes

Most GPs now undergo an annual appraisal,  another management process whether or not it's carried out by another GP. Doctors sometimes forget that management is every bit as much about development and growth as it is about setting objectives, direction and monitoring.

Appraisal leads us neatly into personal development plans, which function as frameworks for Continuing Professional Development (CPD). CPD too is a management process that must be taken into account.

Dr David Martin, Principal Research Fellow, ScHARR, University of Sheffield said: "Appraisees need the management skills involved in being reflective, objective and honest as well as listening, facilitating and mentoring. Educationists must see CPD as a tool for improving performance in a managed context not as an end in itself with its own agenda. Everyone needs training to be good managers or to be good at being managed."

The challenge these days isn't to introduce management to GPs, Professor Martin says, but to de-stigmatise the concept by associating it accurately with its elements; by ensuring that it is seen to embrace the most personal, developmental and widely valued aspects of being a professional.

Plan, do, study, act

One of the many challenges facing general practice is how to bring about the changes required to perform modern primary care. One effective tool to help with this is the 'Plan, Do, Study, Act' cycle. For Sir John Oldham, GP and head of the NPDT, one of the reasons that this tool has been so successful in primary care is because of its similarity to the process of a consultation, which has increased clinicians' acceptance of its use because of its familiarity.

"This tool, along with others of the collaborative methodologies, such as process mapping and teamwork, has contributed to a significant improvement in the quality of patient services. The continued education of these medical management processes is vital."

The six 'P's of medical management education

However, I hear many of you asking: "Isn't medical management education just another name for chronic disease management programmes? We went down that route fifteen years ago, it cost us a lot of money, marginally increased volume of sales but without a corresponding ROI."

    As was argued in Don't Get Frozen Out in last month's Pharmafocus, many companies turned their back on chronic disease management programmes and instead spent vast amounts of money increasing salesforces so they could blitz doctors. However, as the article pointed out, despite this switch many of the bigger spending pharma companies are still failing to maximise their promotional ROI compared to their smaller, more focused rivals and now run the risk of being frozen out altogether if they do not re-enter the disease management arena.

Marketers need to learn lessons from the past and become much more focused on the following six 'Ps' of medical management education: Policy Management, PCO Management, Practice Management, Prescribing Management, Patient

Self-Management and Partnership Management.

Policy management

Policy Management is concerned with understanding the needs of the market place. This means knowing how policy will effect your customers and indeed who your key target customers are: whether they be doctors, nurses, pharmacists, managers or patients. You also need to know if the decision process to prescribe will have to reflect policy changes and if so, how and when? Furthermore, will the policy effect the positioning of your product and how will it be funded?

These and many other questions need to be asked and answered through a mixture of quantitative and qualitative market research. Such research needs to take a multi-disciplinary approach focusing on the policy objectives and outcomes for particular groups of healthcare professionals from clinicians to managers or even other stakeholders.

PCO management

By April 2004 PCO managers will have 75% of the NHS budget. In this context, comments by Mike Farrar, chief executive of South Yorkshire Strategic Health Authority, at a recent conference that chronic disease management is set to become a central area for PCOs take on added significance.

The four existing and subsequent National Service Frameworks (NSFs) including the Cancer Plan, all focus on chronic diseases with the aim of developing integrated care pathways. The emphasis of the Integrated Care Pathways (ICPs) is placed on primary and secondary prevention, increasing patient choice and integrating primary/secondary care.

It is no coincidence then that Mr Farrar is also the lead negotiator for the NHS Confederation on the new GMS (nGMS) contract. He was also speaking at a conference for PCO managers on the new contract and the need for PCOs to involve frontline clinicians when implementing NSFs. PCO managers will need to involve all stakeholders, clinicians, hospital managers and patients in their commissioning decisions and redesigning services.

Tackling chronic diseases requires a 'whole systems' approach if they are to be effectively managed. Within this public health and primary prevention are of critical importance when looking at the management of chronic disease.

According to Professor David Hunter, Professor of Health Policy and Management, University of Durham: "The NHS will become increasingly unable to cope with the growing 'downstream' demands from chronic disease unless action is taken 'upstream' to address the causes of, for example, CHD and cancer." Smoking is estimated to account for 30%, and dietary factors for 25%, of life years lost due to cancer, whereas high cholesterol accounts for 26% and smoking for 10% of life years lost due to CHD."

Professor Hunter says medical education should adopt a life course approach to avoidable chronic disease, based on integrated care pathways so that students are exposed to what managing chronic disease means across the primary and secondary care interface. He says it must also include an understanding of what other agencies, notably local authorities, contribute to lifestyle and well-being.

"The NHS does not have a monopoly of wisdom on chronic disease management," he adds.

When PCOs commission and redesign services, the action will have to be focused on 'upstream' secondary prevention as the NHS will be unable to cope with 'downstream' demands on hospitals and other services.

As Dr Tony Snell, medical director, Birmingham and Black Country SHA and Co-Chair, GMS contract negotiating committee, NHS Confederation, points out: "The new GMS contract quality and outcomes framework (Q&O) for primary care is the most advanced and innovative model of its kind in the world. If it is successfully implemented, it will deliver huge benefits to patient care."

The Q&O framework is a clinical governance framework that maps exactly across to the current CHI seven pillars. It also provides the resources and information management support to enable practices to systematically manage patients with the commonest chronic diseases, such as CHD, diabetes and COPD.

The nGMS contract establishes a set of organisational standards that will enable these clinical standards to be delivered to the highest levels in a risk averse environment. If it is implemented fully and in conjunction with secondary care it will equate to an NHS version of managed care. The contract encourages and enables the appropriate use of different professionals and skill mix to provide the management of stable chronic diseases allowing GPs to concentrate on newly-diagnosed and unstable patients. This is why the new contract is with the GP practice rather than the individual GP. Effective, process-driven practice management will be the key if the new contract is to be successfully implemented.

Practice management

Practices and PCOs will need all the help they can get in this task. Local authorities, for example, will need to help with the upstream measures and a briefing document from the National Primary and Care Trust Development Programme (NatPaCT) on the Q&O framework notes that many pharmaceutical companies have considerable experience in supporting chronic disease management.

NatPaCT also recommends PCOs and practices need clear protocols of partnership working. That is why the NHS Alliance and the ABPI are currently conducting a survey on the NHS/pharmaceutical industry partnership working in this months edition of Primary Care Partnerships (PCPs).

The new Quality Care Coordinators to be appointed in many practices will, along with the practice manager, become key customers for pharma companies. It is they who will successfully change clinical behaviour at the practice level.

Practices themselves need to focus on processes and on programmes, such as the Medicine Management Services Collaborative, and encourage risk management concepts to be embedded within procedures. In terms of implementation, practices will need practical help in many areas of implementation.

Areas include setting up accurate and contemporaneous disease registers; ensuring IT software is fit for the purpose and can record the essential read codes; developing real-time audit; audit training of practice staff; tools to check progress on their Q&O aspirational targets; business plans for developing local enhanced and additional services as well as the practice's position on opt outs for Out-of-Hours; developing ICPs for the ten chronic diseases covered by the Q&O framework.

Practices may also need help with setting up and running extra disease clinics and assessing the skill mix of the practice, sharing skills across practices and professionals, such as community pharmacists helping with medicines management.

Prescribing management

Prescribing management will be a crucial area for PCOs and practices. Already 20% of a PCOs' budget is spent on medicines and prescribing budgets will increase when the combined effects of NSFs, the Q&O framework targets and new NICE health technology assessments (HTAs) kick in.

Two more factors should be added to those influences on prescribing: CHAI will be conducting clinical effectiveness and outcome audits and the elderly are now supposed to be having their prescribed medicines monitored more closely. Indeed since April 2002, people over 75-years-old should have had their medicines reviewed at least annually and those on four or more medicines, should have had reviews every six months.

By the start of this year, repeat dispensary schemes should be in place nationally and under the NSF for Older People there should be more help from pharmacists in using their medicines. Added to this there is the development of supplementary prescribing and to a lesser extent Patient Group Directions. Also, from April 2004, a new contract for pharmacists is being negotiated. This will very much be modelled on the nGMS contract and increase the role of community pharmacists.

Patient self-management

As Professor Colin-Thome pointed out earlier, the management of chronic illness can only be improved if systems of care are developed that incorporate patient self-management.

The progression of chronic diseases is widely known and can easily be demonstrated. Professor Pieter Degeling from The Centre for Clinical Management Development at the University of Durham points out that the nGMS contract will, if implemented successfully, slow down the disease progression. However, there is now plenty of international evidence to show that patient self-management can slow down the disease progression even more.

Schemes like those being developed by the Long-Term Medical Conditions Alliance (LMCA) in conjunction with the DoH's Expert Patient Programme, will, coupled with the nGMS contract, slow down the disease progression still further.

Clearly brand managers should now be thinking of developing patient self-management programmes for their brands as this will help with both medicine concordance and slow down disease progression. However, be aware that the type of patient self-management programme will itself need to vary with the disease progression. For example, Diabetes UK and the Diabetes Industry Group are developing a patient empowered Diabetes self-management programme as recommended in the Diabetes NSF. However, the programme will need to change.

Patient self-management education is developing into a crucial need for the NHS. It will in turn open up enormous opportunities for pharmaceutical companies to develop their own programmes and train both clinicians and the increasing number of 'expert patients' currently being trained under the Expert Patients Programme.

Partnership management

The last, but by no means least important, 'P' for medical management education is that of partnership management, the cornerstone of PCOs' work. If changes are to succeed they must:

• Commission and redesign services in partnership with all stakeholders.
• Win the local ownership of such changes across the whole local health and social care economy.

This is probably one of the hardest and most time consuming tasks on the PCOs' agenda. As Dr Michael Dixon, GP and Chair of the NHS Alliance, comments: "Clinicians are vital to commissioning and redesign. Their professional and local knowledge of patients and how things work, means they are best placed to redesign services – with lead primary care clinicians working with their secondary care counterparts supported by a close working relationship with management."

Effective demand management and well-organised care requires full clinical engagement and leadership otherwise neither will happen. Dr Dixon cites the experiences of Kaiser Permanente as showing how important clinical involvement and leadership is to the cost effective management of chronic disease.

"In the future medical education must enable clinicians to fully engage with managers and ensure clinical leadership and buy-in is achieved so improvements can be made to the treatment of chronic disease within the NHS," he says.

Reorientating pharma culture to help

Pharma companies not only help with partnership management, but also work to improve the prevailing NHS culture to partnership with the industry. However, to do this the culture in many pharma companies will itself have to change.

There are still many companies who have large, disparate salesforces focused on different brands within GP practices and hospitals.

This problem is then further compounded by having healthcare development managers, or their equivalents, working in a vacuum on 'non-promotional' initiatives with PCOs, SHAs and hospital trusts. They then also have PR or government affairs departments that will take the lead in the communications with NICE, the national policy makers and influencers.

Integrated campaign for success

As the NHS becomes much more integrated and holistic in nature, so too must pharma companies. The secret for a successful new campaign or product launch must be for companies to produce an integrated campaign with suitable product positioning.

Companies should also have a multi-disciplinary Professional Partnership or advisory board representing all stakeholders in that disease area; give the overall campaign message the flexibility to be focused differently for the various target stakeholders, such as PCO managers, prescribing advisers, practice managers, GPs, patients, hospital consultants and managers; and the campaign must be set up in such a way as to be process-orientated and outcome-driven.

Above all it must embrace med ed's six 'P's if it is to change clinic behaviour at the local level and be replicated nationally.

Clive Johnstone is Manageing Director of Medical Management Services. For more information please telephone 01225 333711