SHAs: the NHS innovation leaders?
pharmafile | November 24, 2009 | Feature | Sales and Marketing |Â Â NHS, shaÂ
Sandwiched between the national NHS policy makers and the local delivery Trusts are England’s ten regional Strategic Health Authorities. The decisions they make have a big bearing on the pharmaceutical industry – but how should we be influencing those decisions?
The key to this lays in understanding their agenda. In the shifting sands that is the NHS structure, one of the most difficult tasks for the pharmaceutical industry is to identify who is making the decisions, and how to influence that decision making process.
The individual clinician – so long the focus of the industry’s sales and marketing efforts – still exerts some influence, but a whole raft of bodies now make most of the choices which determine the success or otherwise of many of the industry’s products. So getting the right messages in front of the right people absolutely necessary, but complex.
There are three tiers of decision-making – at the national level are the policy makers. At the most local level, you have the bodies that we all interact with as much as possible, those closest to the patients themselves: the PCTs.
In the middle are 10 Strategic Health Authorities (SHAs). These were cut down to 10 in 2006 from the original count of 28. These bodies have a new statutory obligation to promote innovation in the NHS (see box), and have been much in the news.
But what is their purpose? What do they represent for the industry? Why and when might we interact with them, and how should we go about doing this?
SHAs are there to ensure that national policy is implemented on the frontline. In addition, although there are many things that the PCTs can happily manage at a local level, some areas of the health service require a broader view.
The two key things which SHAs do that make them important for pharma are Mass Service Provision and, in particular, Area Specialist Commissioning. The former is about providing services which, by their nature, need to be organised at a regional level to ensure effective use of scarce NHS resources such as Dexa scanning for management of osteoporosis. It’s a question of economies of scale, keeping provision within a region, but not necessarily within a locality.
Regional or National Outlook
The rather more important area for us is Area Specialist Commissioning. The 10 SHAs have a specialist commissioning role across a raft of therapy areas, things like paediatric intensive care and children’s and young people’s oncology. And as we shall see, their role here is as much national as regional, so they play a big part in shaping policy.
The specialist commissioners are within the SHA; their job is service provision for those specialist areas, and they will dictate what that service provision looks like. Knowing how that commissioning cycle works, and what and who influences them, is key to influencing these important decisions. If you can reach and influence the right people, it is going to have a multiplying effect, which is much more effective and cost-efficient than trying to do this on a PCT by PCT basis.
There are 35 specialist commissioning areas, and one SHA will take the national lead in each. This means that the SHAs are de facto working on a national basis, albeit that they are individually regional bodies. In effect making common policy decisions and then ‘imposing’ these on a local level.
One of the big issues here is trying to eliminate health inequality – so-called ‘postcode prescribing’. The SHAs are trying to come to a consensus; so unless there is a really good reason, they won’t want to do anything different from everyone else. There will be occasions where individuals SHAs don’t buy into the national consensus, usually driven by geography or demography. But these are the exceptions rather than the rule, and overall SHAs are driving towards equality of access in all regions.
From a pharma point of view, you could argue that this is making life a bit easier, because if we accept that knowing the market is crucial, it’s much easier to do this on a common basis. In effect the SHAs are implementing regional, super-regional and national policies, and that consistency simplifies matters.
So you wouldn’t expect necessarily to be driving different policies in each SHA; what you want to do is make sure there is a positive view of what you are doing across all SHAs –although you might focus on the one which has the responsibility and which is taking the national lead for your particular therapy area.
Pick Your Target
But even if we know that one SHA is taking the lead in a particular therapy area, we still need to know exactly who is making the key decisions – and just as importantly, who might influence that decision maker.
At first sight, the Specialist Commissioners are the obvious target, but in fact there are so many influencers who are better targeted, who are providing the Commissioners with the information and the evidence they need to take the commissioning decisions.
The Commissioners are the decision-makers; but they are not the experts. They may be making commissioning decisions in an area of medicine in which they are not specialists. And they are not going to take advice directly from the pharma companies, because they will view them as having a vested interest, and they couldn’t have an educated conversation with them.
In fact, the Commissioners are basing their decisions on the evidence they get from others (especially Public Health Consultants), so it makes sense that the biggest influence that pharma can have is to ensure that those influencers are armed with quality evidence.
In organisations which are taking decisions about the prioritisation of budgets, the role of patient associations are also significant. These are a very voluble way of getting things up the priority list. So you need to cultivate your patient group relationships, because they are an influencer group taken seriously by the key people within the SHAs, as well as the public health professionals who are advising them.
Unless SHAs have the condition your drug is for high on their priority list, then you won’t succeed. Patient groups are lobbying for ‘their’ therapy area on a national level, although SHAs are of course interacting with patient groups in those areas where they are taking a national specialist lead, which is another reason for knowing the specific interests of each SHA.
Align Your Agenda
So within – and around – the SHA structure there are a number of different roles, each of which need to be approached in different ways, and with a different emphasis to your messages. But the overarching principle is to align your agenda with theirs, and don’t try and sell too much – simply demonstrate how you are meeting their needs, you need to sell to their priorities.
SHAs approach budget planning in exactly the same way that we do in industry, and it’s useful to know their timetable. From June onwards, they are looking at the investment requirements and priorities for the following year. By September, they have the first-cut investment plan, which is then debated and redrawn during the months leading up to December. The plan is approved in January, coming into effect with the new year in April. If SHAs are important for your own therapy area, then you need to think about whether you should be aligning your brand planning cycle with the SHA planning cycle.
Although some in-year budgeting on a reactive basis does happen (based on ‘exceptionality’ rules), you really must interact with this planning process way in advance, because they much prefer planned budgeting.
SHAs make much use of horizon scanning, looking at what is potentially going to impact on budgets. This is commissioned nationally, but the SHAs use it as an important resource, so it is equally important for pharma. If you can influence the horizon scanning process, it will indirectly influence the SHAs in the decisions that they make on a regional and national lead level.
You can’t influence the outcome of horizon scanning but you can affect the direction by providing information. Disclosure is a good idea, by all means give full information so that the conclusion of the horizon scanning is accurate; but then, make sure you know what the horizon scanning is saying, because that is the information that the SHA will be using to influence its own decisions. You need to link what you are saying to the SHAs to what they are reading in the horizon scanning reports.
SHA priorities are not just about cost, they also consider delivery of therapies and all the other issues involved. So you need to be thinking about the other implications of your medicines – for example if they work in conjunction with other therapies or approaches. The SHA is there to take that overview of the bigger picture.
Pharma should be thinking not in terms of being a supplier of drugs, but as being one of a chain of suppliers of therapeutic solutions, which means understanding what our place is in that alongside others as well. Be aware that you are not the whole picture.
To influence the decisions being taken at SHA level, pharma needs to understand what their priorities are, and then make sure that the way it positions itself means that the pharma company is seen as having priorities which mirror them.
That means undertaking early dialogue with them – at a senior level – to ensure that you understand exactly what is going to be important to the SHA; and it also means early disclosure of information and in particular good quality evidence to help influence that prioritisation process.
But it also means making sure that your agenda is – and is seen to be – aligned with theirs. As with so many parts of the NHS, there is still an innate wariness about conflict of interest, and credibility is key. That means you must have a consistency of brand message – you can’t be saying different things to SHAs just because you think that will convince them that your priorities are aligned; you must be saying the same thing to NICE, SHA, PCTs and all other influencers.
And although there might be regional specifics, remember that there are only 10 SHAs, so they will talk to each other and will be looking for consistency of policy.
Now that the SHA structure has settled, and given their new obligations such as innovation (which are not, as we have seen, backed up with significant amounts of extra money), the door is open for pharma to have an influence on the important commissioning decisions being taken at SHA level.
That means getting the message across to all sorts of people, both within the SHAs (directors, specialist commissioners) and the external people and bodies that will have a big influence on their decisions (public health consultants, patient groups, PCTs, horizon scanners and national policy makers).
Above all, it means building a consistent brand message which shows that your aims are aligned with their agenda. Despite the common suspicion of the industry, SHAs have realised that they have to work with the industry to achieve their aims. It’s now up to us to make sure we play their game to overcome that suspicion.
THE DRIVE FOR INNOVATION
One of the reasons that SHAs are so talked about at the moment is a new statutory obligation on them to stimulate and promote innovation within the NHS in their regions. This need to demonstrate that they are driving innovation within the health service has been assimilated in different ways by each SHA, but most have recognised the need to involve external partners is achieving this aim.
For example, the East of England SHA has set out in a published document how it intends to meet the obligation.
“We have set ourselves a firm foundation for how we stimulate and promote innovation by completing a review involving industry, academia, the NHS and other partners, which has informed our strategic framework for innovation. This stressed the need for a coalition of partners to be formed across East of England, so that we draw in expertise and drive from all parts of the innovation landscape.
“Within all of our work, we are paying special attention to what work and initiatives need to be aligned with our partners and how we prioritise efforts in order to maximise the impact on some of our regional priorities. We are in the process of setting up an Innovation Council of all the key stakeholders, together with a supportive network which will align the support available from external sources.”
Specifically, the East of England SHA decided, in May 2009, to develop “a close and effective working relationship between the NHS and business/industry”.
The budget assigned to all SHAs for this innovation initiative is £220 million over five years, which when you split it down amounts to between £4-5 million per SHA per year – in effect a drop in the ocean.
Some observers in pharma observe that the amounts are so small that they are not worth the effort – but this rather misses the point. Because demonstrating innovation is a legal obligation, this can be a useful button for pharma to press, and companies who can show that their own innovation agenda is aligned with those of the SHAs are likely to be listened to.
Gerard Doherty is a managing consultant at The MSI Consultancy. Tel: +44 (0)1252 748600 or Email: gdoherty@msi.co.uk
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