New customers in the new NHS

pharmafile | July 10, 2008 | Feature | Sales and Marketing |  NHS, industry relations, marketing 

No-one in pharmaceuticals or the NHS needs to be told their world is changing dramatically. The proof is all around, and new evidence appears almost daily.

Companies that understand what's going on will have a competitive advantage – for they will know better than anyone who in the modern NHS influences and decides purchasing issues. But who among us knows what the NHS will look like when the current era of turmoil is over?

To make sense of the situation, I turned to two specialist consultancies working in market access in pharma; policy experts from the NHS Confederation and the ABPI; and a PCT chief executive.

The differences between their perceptions were striking – but so were the areas of agreement.

Dr Robert Hollamby runs the market access specialist consultancy Total Healthcare Solutions, a well-established outfit that has worked with, or is still working with, as many as 50 clients. He's amazed at the disparate changes taking place in the NHS today.

"The NHS has always had pilot schemes, but never this many. In the old days there were only a few and if they weren't successful they were quickly forgotten. We only heard about them if they worked well and the politicians decided to take the glory.

"But now we've got experimentation on a grand scale – there are practice-based commissioning and foundation hospitals; private sector companies running from GP practices, some from outside health care and others formed by groups of enterprising GPs; and the prospect of Darzi practices to come, whatever they will be. Often it isn't very joined-up."

The new, more commercially-minded healthcare providers will be very tight on costs, says Hollamby, but there will also be new opportunities. "The new organisations will be commercially-oriented, and may find they have things in common with pharma. More than that, there may be opportunities to work together to develop projects and services if pharma can respond to the new organisations' needs.

"There's an opportunity to offer something that's more service-orientated, more supportive, and that will ideally integrate company products into the service. We've seen all sorts of possibilities including specialist nurses, and disease specific clinics and so on, even though they can't be asked to prescribe specific products.

"There will be a greater variety of customers with different perspectives, functions and views. Local knowledge about who is driving what and who are the decision-makers will be crucial, and will require sales people with a broad perspective. It will be very different to talking only with prescribing doctors."

Hollamby speculates that it might be better to segment the new market by customer type, rather than sales territories, with perhaps one rep dealing with commercial primary care providers and another dealing with more conventional GP practices.

Whether or not that route turns out to be the one to follow, the new environment will certainly raise skills and training issues.

NHS Confederation deputy policy director Jo Webber agrees there's a lot going on, and points to yet other areas of change. "You've got a pull in one direction to adopt the new technologies and medicines, and there's another pull towards getting the best cost effectiveness out of established medicines by making sure people are prescribing generics.

"There is the issue of how the NHS affords new medicines when the big funding increases we've seen in the last three years are not going to be there any more.

"And there is the extension of prescribing rights to a wider range of professions, which the Pharmacy White Paper has highlighted." The influence of these prescribers will increase as they grow in numbers and prescribe a widening range of treatments, she says.

Another influence is patient access to online pharmacies and sources of information. "We've got people buying treatments over the Internet to cut costs or obtain things they're not going to get through traditional prescribing, and people accessing information from all over the world," Webber says.

ABPI director of NHS policy and partnerships Martin Anderson points to still more changes. "One of the things that's changing is the degree of corporatisation," he says. "It was like a series of franchises with the NHS reimbursing for activities, but now there is a lot more management control. What matters now is finding out who has the influence and having a grown-up conversation with them."

This won't always be easy, however, for Anderson detects a tendency to question the need to talk to pharma at all. A medicines manager he met some days ago was typical, he says: "We were in a meeting with people from a number of pharmaceutical companies. A Trust medicines manager who was present asked the companies to explain why he needed to talk with pharma at all, when he could get all the information he needed from other sources. Answering that question was quite a challenge for the companies concerned."

A new approach to launches?

Brian Lovatt enjoyed a distinguished in-house career, including spells in medical development, sales and culminating in the role of international director for business economics with Glaxo Wellcome. These days, he's working in market access, pricing and reimbursement and running Vision Healthcare consultancy.

He's sharply critical of pharma's enthusiasm for launching drugs that offer marginal or non-existent benefits compared with existing products have given the industry a bad name. Get this issue right, and so many other problems will improve, he says, including the problem of how to address the non-clinicians – pharmacologists, health economists and managers – now influencing the adoption of products.

Pharma, he says, must power its studies for clinical significance, for that's what this group of influencers is looking for – as is the FDA in the US. But this need not necessarily mean expensive large studies are the answer.

"A fundamental error is going for the big indication – for example, all subjects with hypertension. This approach is expensive and difficult, and the results are not necessarily all that favourable." The answer, says Lovatt, is to tackle smaller, more manageable indications first because it's much easier to demonstrate economic benefit if you're solving a clearly defined problem.

"Consider a smaller group of patients such as diabetic hypertensives. The studies don't have to be big. It will be easier to get investigators interested. Recruitment to trials will be faster and much smaller than you'd need for a global indication, and you can end up with a very clean, focused marketing campaign. The product will be faster to market."

There are other advantages. "The product is likely to get rapid adoption because nothing else has been developed for the indication. If that happens there's less likely to be competition – other companies will even avoid your niche."

Lovatt adds that following this strategy makes it easier to get a product with a narrow indication into formularies. "If you ask a formulary committee to look at a new hypertensive with a wide-ranging indication you will meet resistance, as no-one wants to change to a new drug that may not offer much of an advantage and the cost implications could be big. However, if you ask whether they have a slot for a more specific group, such as diabetic hypertensives, you may find it much easier. Also, the case will have been clearly made by well designed studies showing clinical significance in this group.

"Once you've got something clinically significant you will find the non-clinical people involved in formularies will champion it, because if you've got something that genuinely saves money and reduces demand on services, they'll get very interested."

Finally, there's also the issue of doctors using drugs outside their indications and extending their reach. "You get crossover into other indications because once the physicians get to know a product in one group of patients they may well start to use it in another."

And if a drug isn't going to deliver clinical significance? Out it goes, says Lovatt: "Cull it quickly instead of spending a lot of time and effort."

The PCT chief executive

Now meet someone even more trenchant than Lovatt – a PCT chief executive. John McIvor is head of Lincolnshire Teaching PCT, spends £130 million a year on pharmaceuticals and you can be sure he applies his mind to his drugs bill as much as to any other cost.

"I have better contracts than ever before with our 140 GP practices that allow me to look at GP prescribing and say 'that's good' or 'that's not good', or 'that's clinically effective but they're using the highest cost drugs'. Suddenly we're bringing some management into the market place that has not been there before."

How should pharma address that? "It should wake up," McIvor says. "Pharma needs to start taking some big steps. It's no good launching products that offer minimal changes in benefit, or waiting until a product comes off licence, changing its production slightly and saying it shows a 1% improvement in something. We need products that offer a leap."

It seems important to notice that McIvor provides a clear answer to the question posed earlier by Anderson's medicines manager – the one who stumped several pharmaceutical companies when he asked why he needed to talk them when he could get the data he needed elsewhere. But it's an answer that will only help if pharma is willing first to prepare and then release the information.

"Pharma needs to be more transparent about its pricing, and I'd want it to go down a patient-pathway, whole-cost route on a health economics basis so I can understand the whole cost."

For example, McIvor knows that statins have led to surgeons carrying out fewer coronary artery bypass grafts and fewer percutaneous transluminal angioplasties and recognises there's a health economic benefit. But how big is it?

"I'm working with a limited budget, and I want to know what the health economic benefits are against NHS costs."

COPD is another disease area that raises issues when it comes to planning services. "I have significant issues about COPD in parts of my area, and think some of pharma's products might make a difference to lifetime and annual costs, if I understood the effects they would have on the rest of the care pathway. But pharma doesn't talk to me about that, or present the information in a way that helps chief executives."

McIvor won't be the only chief executive who feels this way. Could it be that this thirst for knowledge about the economics and effects on services of using treatments could in future open the door for pharma?

In fact, McIvor wants more. He also wants to know what's in companies' pipelines in order to make better-informed decisions. "Over the coming year we'll be making significant decisions on where to place stroke intervention and rehabilitation services, which will add up in a year to many tens of millions of pounds, and over five years to many hundreds of millions.

"But I don't know what's coming along in the future in terms of safer and more effective thrombolysis – so I'm likely to make some wrong decisions. And so it goes on for every disease group."

This chief executive echoes the ABPI's Anderson in wanting to have a grown-up relationship between Trusts and pharma, and can see no reason why it shouldn't happen. "I say they can tell us this stuff. We're a billion-pound organisation, and we can be trusted with confidential information."

He's also keen to continue to work with pharma on whatever joint projects it might like to discuss. "There have been projects for years about identifying disease, and I've always been willing to get into these kinds of non-product-specific schemes. We've done it with asthma, statins, PPIs and so on, and we've had pharma companies doing promotion for us on sexual health."

However, he's more cautious about the potential for drug companies to be involved more closely in care itself. "If you look at the USA there's a lot of end-to-end provision provided by drug companies, but the nearest we've got to that here is the companies that provide enteral and sip feeds, which often now provide the goods and training, and in some places also provide the nurses."

McIvor doubts the same model would work in COPD and diabetes at the present time, however. "It's hard to see how you could price an end-to-end service and I'm not sure it's in their expertise in this country," he says.

But in an NHS in flux, McIvor isn't ruling anything out. "If you want to talk about end-to-end care services, I want to have a conversation with you, and the most likely areas are heart failure, diabetes and COPD."

Box: Reaching the pharmacologists

There is one underestimated and badly understood group that pharma should be adressing but often fails even to notice, says Brian Lovatt of Vision Healthcare – and it's the pharmacologists.

"The industry has a concept that their market is the prescribing clinician, but one thing it should be doing around the time of launch is working with pharmacologists," he says.

"They're people who make a big difference: they advise the formulary committees and the likes of NICE, but they're normally overlooked because they're not a big prescribing population.

"Pharma needs to realise that pharmacologists read trials and critique them in a way that a company would normally critique them internally, and they are incredibly influential – win over the pharmacologists and the sell becomes much easier.

"Yet I think there are probably only one or two pharma companies in the UK who could even name a pharmacologist!"

Drug company medical departments should be attending the large pharmacology meetings and conferences where new drugs, their chemistry and the studies that support them are discussed.

Using these meetings as route to understand what would be accepted as clinically significant would enable companies to develop a coherent strategy right from the start. "However, that would require marketers to make a change and see themselves as part of the development team," Lovatt adds.

Gavin Atkin is a freelance writer specialising in medical and pharmaceutical topics. He can be contacted at gmatkin@gmail.com.