On October 2nd 2002 The Department of Health published ‘Improvement, Expansion and Reform: The Next 3 Three Years’, its planning and priorities framework for 2003–2006. This document sets out what NHS organisations need to do over the next three years and identifies the national priorities and targets that organisations need to build into their local plans. In the preface to the document, Nigel Crisp, NHS Chief Executive, explains that making progress over the next three years will be demanding and difficult and that all NHS organisations will need to:

• focus on priorities whilst accepting that the NHS cannot make progress at the same pace in every area
• extract the maximum value from every pound
• be prepared to change old practices, be creative and take uncomfortable and difficult decisions in the drive to improve quality and respond to people using the services.

Underpinning these aims are an acceptance that the NHS needs to go through a cultural change at all levels in order to embrace diversity in provision and choice for patients and that this can only be achieved by the increased involvement of the pub-lic, NHS staff, service users and other local partners. To encourage these changes, a new system will be introduced that will link payments to results and so increase the incentive for delivery.

The planning framework

In the past the NHS has based all of its planning around an annual cycle. This has lead to time pres-sures for staff, the requirement to develop multiple plans and claims of not being able to plan for the medium term. In order to address these issues, a new system is to be introduced that will allow health services to be planned over a three three-year period supported by three-year budgets from April 2003. Running in parallel with health, local authorities will also be able to plan the distribution of resources required for social services over a three-year period. Against this background, the following six steps are expected to be followed by each NHS and local authority organisation:

• identifying the national and local priorities and the key targets for delivery over the next three years
• agreeing the capacity needed to deliver them
• determining the specific responsibilities of each health and social care organisation
• creating robust plans which show systematically how improvements will be made and which are based on the involvement of staff and the public
• establishing sound local arrangements for monitoring progress and NHS performance management which link into national arrangements
• improving communications and accountability to the public locally so as to demonstrate progress and the value added year on year.

The priorities

The document clearly identifies the health and social care priorities for the next three years, which are:

• Improving access to all services through better emergency care, reduced waiting times and more choice for patients
• Focusing and improving services and outcomes in five main areas
  • cancer,
  • coronary heart disease,
  • mental health,
  • older people
  • improving life chances for children
• Improving the overall experience of patients
• Reducing health inequalities
• Contributing to the cross-government drive to reduce drug misuse.

If you are currently promoting products which are linked to the priorities above, e.g. a statin or an atypical antipsychotic, then you are likely to be welcomed by your customers, particularly if you can demonstrate how your product can help the NHS achieve the targets linked to these areas.

Building capacity

In order to deliver on the priority areas described above, it is accepted that additional capacity will be required in terms of staff, facilities and equipment and it may also be necessary to involve new organisations in providing service and care, includ-ing the private sector. The guidance gives details about the national assumptions that have been made in respect of the level of capacity that will be needed to deliver the targets in each priority area and organisations will be expected to take these into account when developing their plans although local circumstances can also be taken into account. Each NHS organisation is expected to work with local authorities and other local partners to clearly identify the increases in capacity needed in the following three key areas:

• Physical facilities
• Workforce
• Information management and technology.

Guidance is also given on the national requirements in each of these areas.

Organisational responsibilities

The implementation of the plans will depend on the NHS adopting a whole system approach that ensures that there is local sharing of performance and financial data, particularly between PCTs and health care providers such as acute hospital trusts and GPs, to inform local planning. The planning process will need to involve all the relevant organi-sations and the front-line staff that are needed to make the vision happen, e.g. staff in GP practices will need to be involved through improved engage-ment with PCTs. The planning framework identifies a lead agency which will be responsible for ensuring that the process of developing plans is robust and which will take responsibility for the final product. The priority areas are divided between the NHS and social services as illustrated in Table 1 below. Where the NHS is the lead, strategic health authorities will be responsible for ensuring that the process and the outcome of planning is robust. Where the lead is joint, PCTs and local authorities should locally agree lead arrangements at the beginning of the planning process. If you are promoting a product in mental health or for older people it is possible that you may need to identify key targets in the local authority or social services department if you want to influence the local planning process. This has not been a tradi-tional area for members of the pharmaceutical industry to engage with and guidance may be needed from pharmaceutical companies’ medical departments to ensure that the ABPI code of prac-tice is not breached by promoting products to non-clinical staff.

Planning – a bottom-up approach

Within the NHS, planning will be from the bottom up, starting with those professionals actively involved in the delivery of healthcare to patients. PCTs will take the lead on planning and will be responsible for creating local plans which describe health and service improvement in their area. These plans will be developed using local clinicians’ knowl-edge, as well as patients and the public, and will address the needs of the community as a whole and incorporate national priorities. Each NHS trust will be responsible for creating its own plan, which shows how it will deploy its resources to deliver on both national and local priorities and fit within the plans of its PCT commissioners. Strategic Health Authorities will bring together these plans and will work with Workforce Development Confederations to create the Local Delivery Plan, which will include the workforce plan. The Local Delivery Plans when taken together will make up a coherent national picture and councils should also contribute to these plans, particularly where they are leading on one of the joint priority areas.

Local Delivery Plans - a new planning process

A new NHS planning system has been designed to allow organisations to produce a three-year Plan. The essence of the new system is for all the current national planning requirements for the NHS to be replaced by a single three-year Local Delivery Plan. This mirrors the recent changes for social care where there is already a reduction in the number of plans required to be submitted to the centre, and further work being undertaken on simplifying local govern-ment planning requirements. The Local Delivery Plan will be significantly different from previous plans e.g. HIMPs and SaFFs, and it will need to clearly identify the expected progress or milestones for each priority area over the three-year period. In general terms it will need to identify quarterly or annual milestones but in a small number of critical deliverables it may need to show planned progress on a month by-month basis. The Local Delivery Plan itself will be a ‘“live”’ document which can be amended, with corrective action being taken if delivery goes off course or if new initiatives are being taken as new opportunities arise. These adjustments will generally be made fol-lowing quarterly and annual monitoring. There will not be an annual planning round to replace the cur-rent Service and Financial Frameworks (SaFFs) pro-cess but a new three-year plan will need to be developed within the third year. This could be vitally important for new product launches that may have an impact on local budgets because if they are not accounted for in the three-year financial plan it is possible that they could be ‘“locked out”’ until the next planning cycle and not used locally. The three-year financial allocations to PCTs will be announced in November 2002 together with a national price tariff which will detail the costs that a PCT should expect to pay for a defined procedure from an Acute Trust. This means that PCTs will be very busy this year as they deal with the manage-ment of a three-year plan and a three-year budget for the first time. The final Local Delivery Plans will be published in March 2003 and it will be a key documents for local sales teams to access in order to ensure that they are aligning their activities locally with the priorities of their customers.

Performance Management

Under the new arrangements it will be much more important for local organisations to have good monitoring arrangements in place so that they can amend their plans and take action where necessary during the course of these three years. The arrangements for monitoring and performance management in the NHS are :

• each organisation will have its own system. In addition each organisation will need to make arrangements to report to their staff and the public on performance
• PCTs will hold provider organisations to account for the delivery of services which they have commissioned StHAs will hold all local NHS organisations to account for performance
• The Department of Health will hold StHAs to account for the performance of the NHS within their area.

Monitoring and performance management will focus on the targets for the next three years and there will be routine monitoring of national standards where appropriate. Part of this new system will be the development of new inspectorates for both health and social care which will have the responsibility for assessing overall performance of organisations and for the publication of perfor-mance ratings.

Improving accountability and demonstrating added value

The NHS is transforming itself into an organisa-tion which truly focuses on its patients, designs its services around them and offers them choice and involvement. Its success will depend on the involve-ment of very many people and organisations and on the support of patients and the public. The core document for the public will be the PCT’s Patient Prospectus which describes services and perfor-mance in their area. Every NHS organisation should be able to demon-strate the value that is being added and this will depend on its activities and local circumstances. It is expected that every organisation will be able to demonstrate that is has added value at least to the level of any additional funding it has received and that it has secured a minimum 1% increase in cost efficiency and a minimum increase in quality equiv-alent to 1% of its budget. ConclusionThe new Local Delivery Plans are going to show how the NHS, working with social services and other partners, will make visible improvements, expand and reform services over the next three years. The national picture is important but it will be the local plans developed by each PCT that must be under-stood and utilised by local sales teams if they are to effectively engage with their customers over the next three years. The delivery of these local plans will lie with the people you call on every day – the front-line staff – and therefore anything you can do to help them deliver will be valued. Why not ask your marketing colleagues how they intend to help you sell your products in light of the new environment, because change is needed and it needs to start now!

By Andrew Platten MSc MRPharmS HealthGain Solutions Andrew is the NHS Alignment Manager at HealthGain Solutions Limited. He is a pharmacist with experience in community pharmacy, NHS pharmaceutical advice and has over seven years experience in a variety of sales and marketing positions in the pharmaceutical industry. copyright HealthGain Solutions

In the previous four articles we dealt with the causes of sales call reluctance and how it can dramatically affect the productivity of sales people. Since last month’s article, in which we explained how to help cure this condition, we have received many enquiries relating to another issue that we briefly introduced – that of ‘organisational contamination’. Sales call reluctance is ‘learnt’, and certain unproductive (but very comfortable!) behaviours for sales people can become habits that quickly become a way of life. It is also infectious and can be ‘passed on’ to other people like a dose of ’flu, contaminating others who come into contact with it: Example: A Manager who feels uncomfortable presenting to large groups of Consultants, or using the telephone to make appoint-ments, may well end up with a team of Medical Reps who feel the same way! If these ‘influencers’ can limit the potential of the business at this level, can you begin to imagine the danger for organisations if any of their strategic decision makers are allowed to do the same? When these decision makers are conflicted about the role and legitimacy of the sales process, policy inconsistencies and organisational spasms start to degrade the sales effort.

A company is in danger of producing a group of professional visitors rather than sales people.

Although the results can be very damaging, the outward signs can sometimes be hard to identify and so, before we look at some of its sig-natures, let’s first define what we actually mean by contamination.

The footprint of contamination

People who are in a position to influence sales policy, process or practices, and who also suffer from sales call reluctance will uncon-sciously include their own personal fears in everything they do relating to prospecting and initiating contact with potential customers.

The sources

Within all sales environments there are many people who have some form of influence over how others work and behave. Within most com-panies, there are three ‘layers’ of influence who tend to have the most serious impact:

• Senior managers

• Sales managers

• Trainers.

Whether these people have worked their way up through a sales grade; been groomed for their positions by education and business studies, or a combination of both, they will have experienced things in their lives which will have influenced their views on prospecting and sales. With all of these people these experiences will have come from their family, friends, colleagues, ex-managers, peers, etc and subcon-sciously they take this with them into their sales careers. Some of these influences may include:

• the embedded prejudices and perceptions of their family and friends towards ‘sales people’

• concerns and misgivings of colleagues and peers regarding certain aspects of the sales role

• the memory of the pain and discomfort of failure (even if it only happened once!)

• ‘war stories’ from role model ex-managers of what ‘doesn’t work’ when trying to get more business.

Naturally, all of these individuals will have a direct and immediate impact on how new and existing sales people ‘learn’ to work in their business environment – after all, why else would we have trainers and managers in the first place if it wasn’t for the fact that we wanted the new recruits to learn from them? And whom do we look to for guid-ance if not the senior managers? Of course, each one sits in a different position within the organisa-tional hierarchy; each has a varied range of responsibility and therefore their actions, behaviours and decisions tend to impact on the sales force in different ways.

The influence of sales managers What is clear is that there is an extremely strong correlation between the sales call reluctance profiles of sales people and the people who influence their sales lives. What we showed last month was an example of the type of profile that is available to determine the levels of sales call reluctance exist-ing within individuals.

By Martin Perry E-mail: info@remap.co.uk Web: www.remap.co.uk Remap specialises in Managing Business Performance, and is run by Directors Martin Perry, Tim Tolman and Ian Saunders. To discover more information about overcoming Sales Call Reluctance and to find out what else they have to offer your business, you can contact them using the information above. (Copyright 2001 Behavioral Sciences Research Press, Dallas, Texas. ALL RIGHTS RESERVED. Reproduced with permission)

The long awaited launch of the first insulin inhaler in European markets is likely to be almost two years away. While pharmaceutical companies and patients alike await the results of long-term safety studies from Aventis/Pfizer’s Exubera, competing inhalation technologies, as well as other emerging insulin delivery technologies, are progressing steadily through clinical trials.

Focus on non-invasive drug delivery in diabetes

While systemic delivery of drugs through the pulmonary route is still regarded as a very potent option for strengthening use of large molecule drugs, the profitability of marketing this technology for insulin delivery could be limited by the intense competition expected for non-invasive insulin delivery. The sheer number of inhalation delivery devices for insulin in clinical trials suggests an extremely competitive environment in future years. All the major players in the European insulin market have invested in inhalation delivery. Companies include Aventis, Eli Lilly and Novo Nordisk, who collectively commanded more than 96% of European insulin markets in 2001. Considering the added marketing power of Pfizer to co-promote Exubera with Aventis, the promotional strength for market-ing inhalation insulin in Europe is enormous.

Commercial potential in European markets

Much uncertainty exists regarding the commercial potential for inhalation insulin in European markets. Few doubt that demand from patient side will be strong, but many argue that issues over price of treatment, long-term safety, dosing accuracy and the lack of basal insulin for inhalation delivery will seriously impede widespread uptake in European markets. The price of daily treatment with inhalation insulin is likely to become the single most important barrier to widespread reimburse-ment of insulin in cost-conscious European markets. While the non-invasive nature of inhalation delivery is likely to improve compli-ance for some insulin users, payers could very well perceive the technology as a necessity for few patients and a mere convenience for the majority. The delivery device for insulin has been an integral part of marketing insulin since the first insulin pen entered European markets in the mid-eighties. Although the price of the insulin itself is likely to gain greater impor-tance for inhalation insulin, device-specific issues could prove pivotal in securing success in European markets. Frost & Sullivan anticipates the patient base for inhalation insulin in Europe to account for only a small proportion of diag-nosed diabetics. Given the much higher price of treatment with inhalation insulin, these patients are expected to command a dispro-portionately large cash market share of European insulin markets. Competition over this small, but lucrative, patient segment could very well force pharmaceutical companies to lower margins on inhalation insulin, or introduce subsidies for inhalation devices in order to win over new or established inhala-tion insulin users.

Picking the winners

Many recognise that the winner of the battle for inhalation insulin patients will have to succeed at two vital disciplines. Firstly, the company must be able to offer a competitive price of daily treatment, since this is likely to be the focal point for payers in European markets. Clinical data on bioavailability already suggest which technologies are most efficient at inhalation delivery, but production efficacy could prove equally influential on the market price, and very little information is currently available regarding this parameter. Secondly, the company must market the best device for inhalation. Devices currently in development offer very different attributes, and it is still too early to predict which ones will be perceived as most important by end-users and payers. While marketing power can help define the characteristics end-users and payers should regard as most important, some very tangible parameters such as dosing accuracy and size of the device could yield competitive advantage for some inhalers over others regardless of promotional spending.

Competing insulin delivery technologies closing in

As competitive and challenging as the marketplace for inhalation insulin may appear, Frost & Sullivan regards alternative emerging insulin delivery technologies as the strongest threat to the profitability of inhala-tion insulin. Already well into clinical trials, buccal, oral (tablet form) and transdermal insulin delivery could very well prove to rival the convenience advantage of inhalation insulin only few years after European launch of inhalation insulin. Transdermal insulin delivery is largely expected to deliver basal insulin, and there-fore should be regarded as more of a comple-ment than a substitute for inhalation insulin. However, the ability to provide basal insulin could prove to be very important in the large and growing type 2 segment, and could thereby deprive inhalation insulin of much of its long-term growth potential. Buccal delivery could very well market with a price similar to inhalation insulin, but with-out the same uncertainties over its long-term safety profile as pulmonary delivery devices have experienced, since pulmonary fibrosis was discovered in a patient participating in clinical trials. Eli Lilly could launch buccal insulin in European markets as early as 2007. Insulin tablets, should they prove to be safe and have similar dosing accuracy to inhalation insulin, are likely to have the greatest impact on inhalation insulin rev-enues. Two projects are currently in clinical trials, of which one has already signed GlaxoSmithKline as the global marketing partner. The uncertainties regarding which insulin delivery technology will be the most success-ful is unlikely to be determined with clinical data alone. The promotional spend will play a very important part, and with inhalation technology already associated with the major insulin companies, it should be able to make the most of the advantage of being first to market.

All the eggs in one basket?

At this point in time, inhalation devices appear to have the advantage of both time to market and strong marketing partners. Several promising delivery technologies for insulin, however, are still without marketing partners, and some of these do have the potential to offset the head start of inhalation delivery by more efficient or convenient insulin delivery. So far only Eli Lilly has invested in more than one non-invasive delivery technology for insulin. Developing both buccal and inhalation insulin, the company has effectively diversified some of the risks of developing just one delivery technology. At this point, the drug delivery companies developing transdermal insulin delivery are all without marketing partners. With some of these companies currently performing phase II trials, major insulin companies should already now be beginning to investigate whether this technology would fit their insulin portfolio.

Profitability of inhalation insulin

 At least four major pharmaceutical compa-nies are likely to compete in the European inhalation insulin segment, which could be adversely affected by other emerging insulin delivery technologies. Given the promotional spend needed to launch a novel delivery tech-nology, there is no guarantee that all of these companies will be able to make a profit from the technology. As always, outcomes of clinical trials can alter the prospects for all the insulin delivery devices currently in develop-ment, and the outlook for inhalation insulin would certainly look more attractive should some of the competing technologies fail in clinical trials.

By Morten Soegaard (Frost and Sullivan) Mr. Morten Soegaard, is one of Frost & Sullivan’s European research analysts in the pharmaceuticals area. He is currently researching the European market for Inhalation Insulin and wrote this article focus-ing on his current research findings.

The pharmaceutical industry regulates the activity of its sales people more than any other, and probably has one of the most challenging markets in which to sell their products. The Association of the British Pharmaceutical Industry (ABPI) has an ethical Code of Conduct to which most pharmaceutical companies adhere, and medical representatives must pass their ABPI exams within two years if they are to stay in the profession. However, there is still one area where sales representatives vary enormously: the building and maintaining of strong customer relationships – the foundation stone of any sales activity. Medical professionals demand excellence and tend to make time to see only a few selected sales people, if any at all.

The representatives who establish the most profitable relationships are those who appear professional, are credible, and who offer a genuine service to their customers. Whilst the ABPI examination provides the evidence that medical sales personnel have a sound knowledge of their subject and the NHS, relationship- building and selling skills are often left to field sales managers to deliver. Medical professionals often take a dim view of drug company salespeople, not because they lack knowledge about the phar-macology of their products, but because of sloppy or pushy selling techniques. One clumsy detail can shut the door to further progress and leave the customer with a permanent dislike of sales people in general.

Dr James Ward, GP, agrees: “I am regularly contacted by drug sales representatives, and am reliant on their claims to some degree. However, I need to be certain that not only are they fully up-to- date with the products they are selling, but that they also have the integrity and professionalism to give me information which is useful and relevant in the context of my practice, my PCT and my prescribing formulary. They must also be succinct, and sensitive to my priorities and time constraints.”

Of course, just like the rest of the British population, doctors don’t necessarily complain about poor salesmanship – they just restrict their accessibility. Many pharmaceutical companies have recognised the problem and are now encouraging their employees to seek formal sales qualifications such as those accredited by the ISMM to demonstrate to customers that they are safe to let in! Some of these qualifications, which can be gained either in-house, externally or via distance learning, are now recognised by the Qualifications and Curriculum Authority as part of the National Qualifications Framework, and they are fast becoming the benchmark of sales professionalism throughout British industry and commerce. There are also advanced sales qualifica-tions for Key Account Managers. In terms of sales representatives’ self-develop-ment and career progression, such accreditation also provides concrete proof of their ability and integrity, demonstrating that they have the appropriate knowledge, practical competence and commitment required for a career in medical sales. If, as an industry, we can be proactive in improv-ing the perceptions our customers have of the way in which we sell to them, then individual pharma-ceutical companies can also become more efficient through the use of leaner, more professional sales teams. The benefit to the individual representative is obvious – an elevation of stature in the eyes of colleagues, employers and customers, leading to a longer term, more rewarding career. In pharmaceutical sales, the timing has never been better!

About the author: Patrick Joiner is CEO of the Institute of Sales and Marketing Management, http://www.ismm.co.uk