New NHS, new customers – tips from the frontline
pharmafile | November 21, 2012 | Feature | Manufacturing and Production, Medical Communications, Research and Development, Sales and Marketing | CCGs, Commissioning Board, Dixon, NHS, Sobanja, pharmafile
In the noisy and continuing debate over health reform, it is worth remembering the aim of the coalition government’s health reform: to streamline healthcare provision.
By putting GPs and clinicians in charge of commissioning services through local clinical commissioning groups (CCGs), patients would be sure of getting the appropriate services, and a market will be created to improve quality and value for money. That’s what the ministers said would be the result – with reduced bureaucracy also promised as a bonus.
Put in that way, it sounded simpler than the existing top-down structure of strategic health authorities, primary care trusts and the rest. However it’s clear the health service is going to be much more complicated than anyone hoped for when the reforms come in April 2013.
What is more, almost every commentator has a different take on how it will all work, and which new bodies will have the most power. This makes it a very difficult and confusing time for pharma. The industry must surely adapt their approach to address their new customers and their influences – but it hasn’t got long to do it.
CCGs and the new NHS and pharma – conference
To help the industry navigate its way through the new NHS: Prescriber and Pharmafocus are hosting a special conference in London on 5 December.
Dr Michal Dixon, GP and chairman of the NHS Alliance – the leading champion of clinical commissioning and CCGs is the NHS keynote speaker. In the chairman’s seat is Michael Sobanja, the NHS Alliance’s long-time chief officer and now its director of policy.
Sobanja is also a consultant advising companies of the nature of the reformed NHS, and brokering relations between the industry and the health service. The two Michaels share a common belief that aligning clinical and commissioning powers with financial responsibility is the way forward.
“The real opportunity for CCGs is to spend the available money and commit resources in a way that meets local needs, because they are in tune with what patients require,” says Sobanja. “In doing that clinical commissioning groups will indeed improve the health of the whole population.”
Dixon is sure CCGs will be powerful in reforming health services from the bottom up. “Given that local clinicians are so often aware of problems with services and how they might be improved, they have a head start in making things better.”
So how are the key elements of the new health service going to work, and what is likely to be their importance to pharmaceutical companies?
Dixon has high hopes for CCGs. “I predict their emphasis will be on service redesign and patients getting more appropriate services more locally – especially for the frail elderly, who often go in and out of hospital unnecessarily, and those with long-term conditions who could be looked after better locally rather than attending endless outpatient appointments.”
However, there are some clear difficulties ahead. One is the CCGs’ tight finances, and there are many who question whether the budget for management costs is sufficient.
“CCGs are getting into gear at a time when commissioning will be more financially challenged than ever,” says Dixon. “Savings to date have been largely through slicing things off through reduced employment and holding back wages, but from now on sufficient savings will not be possible unless local services undergo radical redesign.”
Service redesign – or reconfiguration – has been the aim for a decade or more, but inertia inside and outside the NHS has slowed progress.
“With clinicians leading the commissioning process, there is now a greater chance that service redesign will happen,” he says.
Another issue is the role of the NHS Commissioning Board (NCB), says Sobanja. “One of the major challenges of implementation will be the balance of power between CCGs and the Commissioning Board. You only get these gains, I would argue, if you go local and have the freedoms within a framework of accountability.
“There are occasions when I look at the behaviour of the NCB and feel it is quite centralist in its attitude. But at the launch of the NHS Mandate, Commissioning Board chief executive Sir David Nicholson emphasised that only localism will deliver the challenges of the health service – and that the NCB is only there to provide support.
“We’ll see,” says Sobanja. “He’s got to walk the walk, not just talk the talk.”
Dixon is less sceptical about the stance the Commissioning Board may adopt.
“So far its language has suggested a much more equal relationship between frontline clinicians and the centre than there has been previously,” he says.
“Also, both the Commissioning Board and the CCGs’ representative organisation NHS Clinical Commissioners (NHSCC), have ensured the NHS mandate allows flexibility for frontline commissioners without overloading them with central targets.”
Another issue often raised is how effective CCGs can be in achieving a consensus among GPs that will allow them to execute plans with the support of their members. Sceptics point out that GPs are well known for defending their personal autonomy.
However, Sobanja argues the era of fierce independence is over: “I would argue that in recent years GPs have become much more corporate-minded, driven by things like QOF (Quality and Outcomes Framework) and the various challenges around them.”
Dixon adds that democratic forces will also encourage CCG members to find ways of working together. “No CCG would ever be able to withstand a vote of no confidence by the majority of its frontline clinicians and GP practices. Inevitably there will be problems… but these are likely to improve as time goes by.”
There remain doubts about many of the other new bodies created by the reforms – including clinical senates. These are independent local groups made up of clinicians, but it remains unclear what their exact role will be. Dixon suggests senates could provide ‘air cover’ to CCGs who want to implement large-scale local hospital reconfiguration, and help them see-off political battles in which rational plans have had to be abandoned because of vested interests.
Medicines advisors set for smaller role?
But perhaps even more important is the relationship between CCGs and their local authorities.
“Health is determined by a much greater range of factors than simply health services,” says Sobanja. “CCGs and local authorities have got to work together now, and the key to that is how local communities will drive them both in the same direction through the strategic needs assessment and so on.”
The health service hasn’t got a good track record in partnership development, but working with health and wellbeing boards will be a critical factor.
Medicines advisers and managers will lose their PCT roles, and are likely to turn up almost anywhere in the system. “Some are going into local authorities along with the public health department,” says Sobanja. “Some are going into commissioning support services or units, and some are going to be employed directly within CCGs. And some will be in the private sector, selling their services into CCGs.”
Compared with medicines advisers in the PCTs, they are less likely to hold budgets.
Again and again, the story of the post-reform NHS is that each area will be different, and that intelligence gathering exercises, such as local stakeholder mapping to find out where sales and marketing effort is required, is going to be essential to success.
There’s one more point to add. With senates, strategic networks and health and wellbeing boards already in the fray, you might think the web of influences coming to bear on clinical practice in the future was quite complex enough. But not a bit of it – for Sobanja points out that NICE will remain a major player with its technology assessments, guidelines and quality standards.
Marketing to the new NHS
So how do Dixon and Sobanja say pharma should engage with all the organisations vying for influence in the often-complicated NHS post April 2013?
i) Identify key targets within CCGs – The key people will be the prescribing lead for each practice and the prescribing advisers and leaders of each CCG, says Dixon. “Frontline clinicians – GPs and nurse prescribers especially – will remain important target audiences but will be increasingly constrained by CCG-agreed formularies. In time there is likely to be less prescribing outside the local formulary as peer pressure normalises prescribing within each CCG.
Sobanja agrees. “Identify the leading influences in each area,” he says, “and give them messages tailored to their needs”.
It’s a very complicated picture: “The pharmaceutical industry is going to have to build relationships with a far wider range of players than they have done in the past, and will have to find a different way of addressing each one with their particular language, set of beliefs, and their own focus. Tailored messaging will be the name of the game.
“For instance if you take diabetes, the incidence and prevalence of diabetes in East London is five times that in Telford in the West Midlands. So how you approach working in the area of diabetes is going to be very different.”
Even strategic health networks can be expected to vary in their approach from place to place – a strategic health network in the North East of England will have a different set of health problems to the South East of England, he says.
“Traditionally the pharmaceutical industry has identified a single message and applied it across the country, but now the industry will have to reflect local circumstances and the needs of networks and CCGs in local areas.”
ii) Build relationships – CCGs and clinicians are there for the long game, and establishing ongoing relationships will be more important than ever before.
Dixon argues that GPs have generally had a better understanding of pharma than PCTs led by NHS managers, so good relationships may come easier. “The NHS has traditionally had powerful antibodies to profit-making organisations,” he says.
Understanding the issues facing frontline clinicians and CCGs – such as the quality framework, the Care Quality Commission and cash-strapped budgets – will be crucial in terms of pharma being able to help answer the problems that are most troubling to CCGs.
CCGs will need to feel their partners in pharma are ‘on their side’ and that companies are absolutely transparent, so each side can confidently assess situations where there may be a mutual win.
There is no doubt, however, that CCGs will go for options that are cost effective and where patients benefit. That means companies may need to learn to ‘risk share’ with partner CCGs, and to provide something over and beyond the medicine itself.
But Dixon has a warning: “CCGs, their clinicians, and patients will be unforgiving where they feel that trust has been breached and, equally, will be more likely to form long-term relationships with companies that can show a good track record.”
To hear more insight on how best to engage with England’s emerging clinical leadership, register now for the conference – CCGs, the new NHS and Pharma on 5 December.
Gavin Atkin
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