Part 1

The impetus for this article came from a chance discussion with a moderately senior pharma company representative. They were explaining the benefits of being on a recent ‘advanced selling techniques’ course. What was interesting was that whilst they found the course fascinating, it was a shame that this course was not provided earlier in his career. The company’s policy it seems was to provide this course to selected individuals who were successful, but inevitably led to advanced selling skills to those who were senior enough that their face-to-face customer contact was far less than many others within the company below him.

The resulting paradox is a system whereby new representatives who’s entire role is to see customers receives less training in sales techniques than senior members who are often reticent to be called ‘sales reps’.

Why do so many ‘details’ and ‘calls’ go wrong? How many times do you come away from an appointment with a confusing perspective of the call?

The next few issues of the MATRIX looks at some interesting observations you may choose to employ in your next call.

1. NEUROLINGUISTICS – MEETING & GREETING
The 1st meeting with your customer will probably dictate whether or not that customer will want to see you again. Not dissimilar from an interview, the decision will often be based on entry and exit of the candidate (paradoxically candidates peak performance is in mid-interview despite the fact interviewers impressions are strongest near the beginning and end of the interview)

I have an appointment with a NHS HDM/HBM from a Pharmaceutical Company. They have confirmed a few days ago, stated they are a bit nervous to meet me but that they are looking forward to having our 1st meeting, as she is new to this territory.

‘Hello’s’ and ‘Goodbyes’ follow simple social rules of salutation displays. They are intended to transmit friendly signals, or at least absence of hostility. This is why we hug/kiss and cuddle friends that we haven’t seen for ages – in the absence of daily contact we are ‘making up’ for all the little friendly greetings that would have been displayed. If you have someone you consider a ‘good’ customer who displays little or no ‘salutation’ display then think again on your appraisal of your customer relationship. Moreover I can think of a fellow pharmaceutical adviser who rarely gets out of their seat to welcome representatives at their appointment. That is a signal for sure!

2. NEUROLINGUISTICS – PHASES of a PLANNED MEETING

The representative is showed to my door. We shake hands, chat a bit about her journey and difficulty in parking. She comments on my hairstyle and we exchange a joke. I offer to put the kettle on…

Whilst human beings should never be ‘pigeon-holed’ into boxes, there is an interesting exchange that occurs on the 1st planned meeting between 2 individuals.

The first observed action is the inconvenience display. This has already been expressed in some part before our meeting because it is apparent that the representative has traveled from afar to see me (and has awoken at a significantly early hour in the morning!) The inconvenience display may involve standing, moving out of my chair, and offering to take her jacket etcetera. At some point I will need to move out of my home territory and familiar position to welcome my representative – if that is, I want to display friendliness or courtesy.

Do you have customers who cannot be bothered to display such behaviours? Or worse still, they do not realise they are not displaying it. In this case they are leaking their attitudes to you/your company or your product.

The minimum inconvenience display is that of vertical displacement (stand up then sit back down). If I had known this representative or we were good friends, then the distant display (wave, nod, smile) which acts as a recognition may be all that is required (interestingly the hand wave stems from the open display of non threatening greeting in attempt to show one is unarmed).

Significant close displays after the initial greeting (embrace/cheek-to-cheek/shoulder clasp) goes some way to show further affection. Maybe you have met the customer previously. Maybe they really like you or have gained significant trust. Sometimes they are done ritualistically in certain circles.

Interestingly we have also reciprocated a grooming display. Animals do this quite literally (picking at one-another’s fur). Whilst I would be quite shocked (and she too probably) if this representative attempted to run her fingers through my hair, we all demonstrate groom talk – you are looking well today, did you have a good journey, I like your outfit etcetera. We often don’t even listen to the answer. It seems we give compliments and receive them, the precise nature of which is almost irrelevant.

3. NEUROLINGUISTICS – BODY LANGUAGE

Armed with 2 cups of coffee, clinical papers, sales detail and a fancy boxed gift which I am eyeing up expectantly we both take a seat. With the greetings and pleasantries executed, we start on business matters ahead…

There seems to be too many reasons why the meeting may break down and fail its objectives. The first is because the objectives of the representative are often different from the objectives of the customer. Furthermore, the objectives of the representative’s manager and even higher up, the company’s objectives and expectations may not be congruent with what is happening right here, right now in this meeting (think of how often you face the sales-versus-target argument alongside coverage-and-frequency expectations). Add to that a lengthy delay in obtaining the appointment and not a lot of time in which to convey your key messages – it’s a wonder any of these appointments achieve what they do.

The representative begins with asking me of my view of a certain disease. She rapidly moves to the impact of this illness to the NHS and how poorly we are treating this disease in the UK. After a few emphatic sentences on how ‘points means prizes’ she pulls out her paperwork. I seem to be on the receiving end of a one-sided conversation though she does stop at regular intervals, to see if I am nodding in agreement. But how does she know what I am really thinking? Are we both on the same wavelength? Or are we just going through the motions?

One of the observations you may want to look at is your ‘postural echo’. Your company probably mentioned it once at your ITC (remember being locked up for 6-8 weeks in a hotel with lots of new recruits wondering what type of car you would get whilst putting on a few kilos of body weight? well that was your ITC!) It seems that as we begin to share similar ideas and attitudes, the positioning of our bodies becomes more alike (also termed mirror-imaging). These actions are not deliberate – they are as a result of subconscious companionship.

There are many advocates of selling in this way – postural echo to reinforce a silent message of similarity between you and the customer. I don’t know if it works but one can see the value of taking notice of this during your sales encounter. Maybe more provocatively, postural echo may be used in an attempt to raise your own status when you feel you are meeting a difficultly dominant customer. I see this occur with patients. The GP can either help a patient relax by adopting a supportive, listening and understanding posture or they can fold their arms, stay well behind their desk in a dominant stance. I wouldn’t advise experimenting this at your 1st job promotion, but maybe your body echo could mirror the dominant person on the opposite side of the desk. Stay polite but don’t relinquish a sub-ordinate posture. The impact may be more powerful than you had initially intended and the consultant will throw you out for perching your legs on his desk and signalling him to put extra milk in your coffee!

Next month, Neurolinguistics Part II

Over-the-counter (OTC) drugs are medications available to consumers without a prescription. Millions of consumers each year use these formulations for the treatment of self-diagnosed conditions without physician intervention, because doing so has been deemed safe by regulatory bodies, such as the U.S. Food and Drug Administration (FDA), U.K.'s Committee on Safety of Medicines, and others. More than 80 therapeutic categories have been approved as OTC drugs and range from drugs that fight acne to medications that treat fever, allergy to weight control drugs. While, there is little risk associated with the use of these medications, severe adverse effects can result because of either improper use or drug interactions.

The Committee on Safety of Medicines, an independent committee of experts, advise the British government on safety, quality, and efficacy of medicines. The Committee recently advised that Simvastatin 10mg should be made available as OTC, without the need of prescription. The switch to OTC is good news for people on prescription Simvastatin as they can now lower their cholesterol without regular visits to the doctor and at reduced cost. The low strength of Simvastatin has been considered safe, however, lack of proper patient education can result in number of harmful side effects.

Statins such as Simvastatin work to lower blood cholesterol levels by reducing cholesterol production within the liver. Statins block the liver enzyme hydroxy-methylglutaryl-coenzyme A reductase (HMG-CoA reductase), which is responsible for making cholesterol. Therefore, scientifically, statins are HMG-CoA reductase inhibitors. The benefits of statins include decreasing a patient';s risk for congestive heart disease (CHD). It is estimated that approximately 14.8 million people use Stains worldwide and are credited for saving the lives of more than 16,000 -17,000 people per year. Moreover, in addition to cholesterol reduction, Statins have also been shown to reduce the risk of breast cancer. The low cost OTC statins are expected to extend benefits to more patients with risk of congestive heart disease.

The benefits of OTC Statins must be weighed against the potential side effects. Proper patient education is the key to success of OTC Statins. The patient might experience side effects, commonly termed as ';statin side effects';, by taking higher than recommended dose. These side effects can include headache, nausea, vomiting, constipation, diarrhea, headache, rash, muscle pain, and weakness. Taking other commonly available OTC medications can treat these conditions. However, combination of OTC medication with Statin may result in dangerous drug interactions. A commonly encountered side effect with the usage of Statin and pain relieving medications is Rhabdomylysis, which can result in damage to muscles. Though these OTC pain medications are often considered benign, they might result in dangerous drug interactions when used with Statins.

In addition to the side effects, the patients may not be aware that diet and lifestyle can impact CHD risk. Even while taking OTC Statins, the patient may be exposed to CHD risk because of patient';s diet and lifestyle.

Patient education is becoming crucial as prescription medications such as Simvastatin go OTC. The patient should be adequately educated and informed about the possible side effects and risks of the medications. Though OTC medications are deemed safe, lack of patient education can result in serious side effects.

Upcoming patent expirations in United States for Statins such as Zocor and Pravachol is expected to force companies to explore the opportunity of OTC Statins. While the switch allows companies to sustain their revenues, the FDA';s efforts to reduce healthcare cost will also be complemented. However, this is not a lucrative option for Statins with long patent expiry such as Lipitor and Crestor.

As more prescription medicines go OTC in global markets, weighing benefits with possible side effects will become of utmost priority. Patient education is expected to remain a key strategy for the success of OTC products. Initiative of European countries such as United Kingdom to make Simvastatin available as OTC is expected to be a trial that will be carefully watched by the world.

* Survey finds a third of Europe’s largest companies are hit by material environmental liabilities post deal.

* Brand and reputation are increasingly the casualties of environmental risk in deals.

M&A transactions conducted by some of Europe’s largest companies have resulted in unexpected environmental risks, despite efforts by many of them to identify the threats before the deal. A survey found that a third of companies interviewed had been impacted by material health, safety, social and environmental (HSSE) issues post transaction. The risks are not without cost. Where an issue was discovered post deal, 42 percent found it resulted in higher operating costs and 21 percent in direct financial liabilities.

The extent to which HSSE issues impact corporate deals is highlighted in a new report from KPMG LLP (UK). The report Impact - a survey of Environmental Due Diligence is based on a survey carried out by an independent research company, TNS, of 105 companies from the top 500 quoted companies in Europe. It paints a picture whereby deals in many mainstream economic sectors are habitually revalued or restructured on account of HSSE factors, with many companies admitting to walking away from a deal, especially if it is thought that the HSSE impact will damage the acquirer’s reputation.

Commenting on the report, Stephen Oxley, Head of Pharmaceuticals at KPMG, said: “Corporate Social Responsibility (CSR) is increasingly recognised as key to sustainable commercial success. Whilst environmental due diligence has been on the radar of deal doers for the past decade, there is variable understanding of the broader CSR issues impact transaction success. This is a significant factor in explaining why so many companies still fall foul of environmental risk.”

A large majority of those conducting EDD found that the findings had altered the outcome of transactions. The survey found that:

* seven out of ten companies had pulled out of, renegotiated or restructured a deal as a result of HSSE issues emerging from EDD;

* 67 percent of Risk Category 1 (see notes to editors) and 33 percent of Risk Category 2 companies say that negative EDD findings had led them to pull out of a deal;

* EDD results had led to price renegotiations in 64 percent of cases for Risk Category 1 and 48 percent for Risk Category 2.

* 60 percent of companies were hit by material issue despite conducting EDD.

Oxley notes: “Environmental risks can have a huge impact on deals but the approach taken by companies to evaluate HSSE risk during transactions is variable, even within the same sector. Some have detailed procedures updated annually to reflect the ever changing landscape of HSSE risk, others have no procedures. Some are very commercial in their approach, always linking the environmental finding back to how it could impact business performance, others focussing only on the technical finding itself. And some companies ensure the EDD findings are considered by other ‘overlapping’ due diligence assessments, such as financial, legal and commercial - others do not.”

“These variations mean the scope of EDD is no longer as uniform as it once was. Now two EDD exercises on the same target could prioritise quite different findings for action and negotiation - and one could miss material issues which the other identifies.”

“For example, virtually all respondents recognised the potential for reputation and brand damage from HSSE issues and many companies said they had pulled out of deals when a significant risk of material impact to their reputation was identified. However, only a third of companies specifically scope their EDD to look for HSSE issues which could impact brand and reputation. Inadequate social and community standards were the most frequently quoted issues to present material brand and reputation risk on a deal - issues which are not normally included in the scope of many EDD investigations.”

The research identified a number of critical success factors:

companies need to have a commercially driven scoping and assessment approach, which focuses on understanding the business performance implications of HSSE issues;
EDD findings should be integrated into the commercial, legal and financial due diligence assessments;
the investigation should look beyond just the environmental agenda and adapt the scope to look at broader corporate social responsibility risks, especially when considering brand/ reputation risk;
the evolution of EDD cannot be at the expense of investigating the traditional areas of risk, such as contaminated land and regulatory compliance. Robust technical skills remain critical.

Oxley concludes: “The companies which are incorporating the ‘critical success factors’ are the ones suffering the least from post deal problems - and in the long run more likely to be successful in their M&A transactions.”

KPMG Transaction Services provides assistance, including financial and commercial evaluation, on M&A transactions, acquisitions and disposals, debt offerings, project and structured finance and related due diligence and working capital reviews.

PPDP is being driven through PCTs, usually by Clinical Governance Managers, via Primary Care Development Managers, and through Practice Managers at practice level. PDP, on the other hand, is within the remit of the PCT appraisers group, though summaries of appraisals and PDPs do get copied to Clinical Governance leads. CPD tutors, who used to be in charge of PGEA, now tend to have more of a role in advising on the topics for PCT-provided Protected Learning Time sessions. They may take sounding from the appraisers group and clinical governance as to which issues are of most educational concern to GPs, though their role is becoming increasingly focused on the educational needs of the whole primary care team rather than just the GPs as under PGEA.

Potential difficulties

Funding
Many of you will already be supporting PCT-organised ‘Protected Learning Time’ (PLT) events. These are the 21st Century equivalent of the Postgrad meeting – but with a dilution effect, with not just GPs, but nurses, practice managers and admin staff attending. These are worth supporting provided you set your objectives carefully before attending – always obtain a delegate list in advance and target whom you want to speak to. These are the type of meetings where the more ‘retiring’ (or very busy!) customers may be contactable, enabling call backs later. Also, try to share the cost of having a stand. Sometimes they are worth supporting if you have pressure on call rate, through the chance of getting multiple high-quality calls during the brief lunch or tea breaks is slim!
Increasingly, PLT alternates between mass education events and practice-based sessions. These latter events enable practices to attend to their specific learning agenda, for example, as identified in their PPDP and PDPs. These can be excellent events to sponsor for target practices, as the duration of time representatives can spend with customers is long, and often the topic allows for representative involvement to sit in and learn alongside customers. Many representatives now provide a range of educational topics to offer practices to run at their practice-based PLT, either provided by the company, or via outside agencies like the Healthcare Partnership. Topics to offer should meet the needs of the Quality Framework, for example, but why not ask the practice manager what the PPDP is aimed towards, and what learning needs staff’s PDPs have highlighted?

Time
What about in PCTs where PLT is not provided? It’s fair to say that lunchtime meetings will be more popular here, as well as meetings encroaching into the ‘half day’ – though encouraging staff to stay for these events is difficult, especially part-time staff. In general, Practices in ‘non-PLT’ PCTs find less time for ongoing education during the working day; so will either need to be offered evening meetings, or weekend workshops – or you may just struggle and instead focus on those practices that do have PLT. Time for full day training, for example Practice Away Days, is at an absolute premium, and requires that the practice provide locum cover, which costs money and is thus unpopular. However, many practices do value their annual away days, and find these events stimulating, both for team development and forward planning. These are again worth getting involved in as a sponsor, but can be expensive so reserve for key practices only.

Range of opportunities
Other forums meet regularly and offer sponsorship opportunities. PCTs all host monthly ‘Practice Managers Forums’ – a great chance to meet all the local practice managers in a relaxed environment and find out their needs – or sell your range of value-added services. Postgrad centres still hold GP meetings, though attendee numbers tend to be low in areas also offering PLT. Often LMCs host their own GP events too – be aware of their educational calendar, as these events are usually very pertinent to current GP issues, such as how to make the most of the GMS contract. Ask any practice manager for contact details.
And finally, Pharma-hosted speaker meetings will still be an option whilst marketeers continue to believe that this is a good investment of the brand budget – though surely once you are paying over £100 per head they should re-think if this is money well spent? An alternative is to combine a clinical speaker alongside a second topic of current interest, such as ‘Making money from the Quality Framework’ (one of HCP’s most popular short talks!). This ensures larger delegate numbers and a better cost per head.

The future of NHS education – your opportunity
One thing is certain. The new GMS and PMS contracts are bringing about a revolution in medical education for General Practice. Doctors’ motivations for attending educational events will shift away from the gathering of PGEA points, towards gathering relevant personal education and improving their delivery of healthcare – offering proof of continuing fitness to practice as a doctor (plus the occasional nice meal, with friends, in a comfortable location, free of charge…..) Are you armed with the right tools to identify and satisfy your customers’ educational needs?

Every day you may make progress. Every step may be fruitful. Yet there will stretch out before you an ever-lengthening, ever-ascending, ever-improving path. You know you will never get to the end of the journey. But this, so far from discouraging, only adds to the joy and glory of the climb
Sir Winston Churchill

“To run a marathon is to practice a form of self-discipline based entirely on visualisation. You must imagine yourself doing the impossible and that enables you to do it.”
Harvey Mackay

It’s Monday morning. The usual English rainfall is dripping off the eaves outside your bedroom window. First you groan. Then you wonder: do I really have to work today?

Often, office-based employees simply look to the left or right to find daily stimulation and motivation from their co-workers. But you, as pharmaceutical reps, must rely on yourself to generate self-motivation. Where does the inspiration come from?

As a motivation professional, I know that in order for positive behaviour to be sustained over time, an employer must infuse four key elements into an employee’s life. These are: communication (tell them what you expect of them and how to do it), education (give them the skills to meet and exceed your expectations), measurement (assess who’s meeting your expectations and who needs special attention) and recognition or reward (give them motivation and a reason to care.)

As an individual pharma rep who’s on the road each day, you can’t rely on your employer to touch you in this way, every day. So it’s even more important to self-induce these into your daily work practices to ensure your success. How can you do this? Here are some ideas.

Communication

Create a reliable network of contacts to keep you up and enthused each day.

n Peers. Yes, initially it will seem awkward and contrived. But hey, your peers are in the same boat! Pick out five or so that you can quickly contact each week. Add some new ones or drop some off the list. Share best practices. Whinge a bit! Congratulate when achievements are made: a difficult doctor is seen, a new practice adopts your product. Eventually, motivating yourself and others will become a habit. When you’re down, you’ll have people at hand who can encourage you on. When they’re down, encourage them on. You’ll be surprised at how well you pump yourself up in the process.

n Mentors. Perhaps this is your boss. Perhaps it’s someone you met at a conference or product training. This is someone you look up to. Someone who is a success in your eyes. It doesn’t even have to be someone in the pharmaceutical industry. But this is someone you can ask for advice and who can help you lay down a mental path toward success. Take this person out for coffee periodically to help define your goals, identify steps you can take to get there, assess your progress, and help you re-centre and keep you focused.

n Employers. Talk to your boss, your marketing contact, your HR administrator. What tools can they give you to help improve your performance? Are the activity reporting systems too difficult to use? Do you know where you stand on your goals this month? Do practitioners think your company’s product handouts are memorable? Actively engage in improving how you do business. Don’t be a victim to your circumstances.

Education

As you know, every second is critical to the impression you make on a call. Indeed, to maximise your impact, you’re barraged with product and sales training. Education makes it easier for you to do your job well. Think of how much better you are now than just a few years ago?

Now, take an interest in self-training to hone your technique. Go beyond what they’re teaching you in class or over the Intranet. Pay attention to what’s happening around you. A knowledge and understanding of the drivers of the local health economy will help. See what’s in the local papers. Even talk to those health professionals to whom you can’t sell. What are the goals of the General Practitioners (GPs) practice staff, prescribers and the Primary Care Organisations (PCO) board members in your area?

Possibly, GPs will favour seeing representatives from companies who have valuable information and initiatives that help them reach their contracted goals. Be a student of the issues and you’ll be better positioned to relate the features, benefits and services of your product portfolio to the local priorities.

Measurement

They say that poor planning gives poor performance. So don’t just set big, random or vague goals for yourself (I want to sell a lot, earn a lot and retire early). You won’t realise your dreams that way. Like a surgeon, dissect the patient – yourself and your daily activities! What works best for you? What doesn’t? What are the individual small activities you need to do each day, each week and each month to accelerate your success? It’s not one or two big sales that will ensure lifetime goal attainment. It’s all the little itty bitty baby steps along the way. Plan these steps and consciously lay out your path to success. These steps are what build long-term relationships between your products and your prescribers.

Once you determine what you need to do, don’t make it easy to avoid it. Track your performance - Visibly. On big posters around your home office. On the back of your sun visor in your car. On the inside front page of the notepad you carry every day.

Here’s another tip - use a mantra. Something you can say over and over to keep you focused. When I struggle in knowing what to do next or if I should throw in the towel for the day, I ask myself the same thing again: Will this take me closer to my goal?

Reinforcement

Motives can be either intrinsic or extrinsic. That is, they either emanate from you or are provided to you by others.

Consider your intrinsic motives. Can you see yourself receiving a reward for all your efforts? Is it a commission? What’s the difference between £200 and £250 in commission? It’s just £50. Turn that £50 into something tangible. Visualise a Saturday night out for dinner and a movie with your partner. Or think of five new CDs. £50 could be the amount you’ll save each month toward your Canary Island holiday. Can you feel the warm sand sifting between your toes? Suddenly when you visualise your reward, fitting that one extra practice into today doesn’t seem like such a burden after all.

It’s rough out there. GPs and Primary Care Trusts (PCTs) beat you down every day. Nurse practitioners get in your way. So when you do accomplish your desired activities, reward yourself! Make it a simple treat. Or use your network for a moment of bragging. You deserve it!

And take advantage of extrinsic motivates. Take advantage of the training, tools and rewards your employer gives you. It may feel like just one more thing to do, but once you get into the swing of it, it’s soon done. It may take days before you realise how it helped you better position your product or capture the attention of a Doctor.

If you positively change your modus operandi, you’ll change your perspective, your attitude and your outcomes. Improve your day-to-day motivation and eventually, you’ll wake up in the morning and say “Good Morning, Sunshine!” Okay, well, maybe that’s an over statement. You wouldn’t want to shock the household! But what you will be able to accomplish is rolling out of bed without a groan and with a well-planned, well-orchestrated day ahead of you. A day that will bring you a few steps closer to your final dreams.

There has been change in the NHS almost from the moment it began. The compromises that had to be made to get it going meant that the structure and management were far from ideal. The endless series of reforms have been attempts to get things right. Some have made improvements, at least until the next one came along. Many have been just different rather than better.

Now that the government is, relatively speaking, pouring money into the NHS to solve the chronic underfunding, even this is not producing the kind of real tangible improvements that will help it win the next election.

It doesn’t take a great deal of imagination to realise that there may be problems that all the reforms have not tackled. One drawback is that the whole operational culture of the NHS and the use of its own peculiar jargon often makes it difficult for those in positions of power to see the real difficulties that patients face. Such initiatives as “patient experience” and “access” mainly deal with how the patient relates to the system as it is, not as it should be.

Further everyone seems to accept results that should be the basis for a revolution, with absolute calm. Take, for example, a finding from the current Evercare disease management pilots for the treatment of the elderly that “better monitoring and education of older patient populations means that at-risk patients can be identified and treated before hospital admission become necessary.”

This means that these vulnerable people, simply by being looked after properly, could be kept out of hospital and have a much-improved quality of life. So what, one might ask, has happened in the past. Why does it take a pilot to realise that their treatment has been deficient?

Now, because other pilots are producing similar results and because there is a wide range of drivers all forcing change into the same direction, there is the start of yet another reform. It will be called the chronic disease management or CDM reform, and there’s no doubt that CDM will become the acronym-of-choice over the rest of 2004.

It has the possibility to make the kind of patient-centred improvements that could save the government’s bacon, providing the results appear quickly enough.

The History

In the late 1980s pharmaceutical companies identified what was know as disease management as the route to enable them to increase the sale of drugs, and they set up dedicated departments to exploit the concept.

Disease management referred to a joined-up treatment of a disease over the whole of its course. So that, as a patient with a chronic condition moved between hospital, for acute treatment, to the GP, for primary care, and the home, for community care, the care was meant to be seamless. The aim was the not the optimisation of any one stage at the expense of others, so that all decisions had to be taken on the basis of the overall benefit to the patient.

Unfortunately two things went wrong. Companies concentrated on selling more product, rather than developing systems to deliver real patient benefits, and the NHS had neither the infrastructure, nor the culture to provide the necessary services.

So the disease management concept went away.

The US Dimension

However, in the USA where are different drivers, it has been widely realised for some time that disease management is an idea whose time has come. A well-accepted definition, due to the Disease Management Association of America (DMAA) is “A system of co-ordinated healthcare interventions and communications for populations with conditions in which patient self-care efforts are significant.”

The Americans have exploited this idea to the full and, apart from the care deliverers themselves, IT companies have developed dedicated programmes to provide the necessary co-ordination and communication. These firms have promoted themselves from being simply IT outsourcers, to the much more elevated role of disease management enablers. Their importance is emphasised by the Boston Consulting Group’s estimate that the markets for IT-based “disease management” services grew from $68 million in 1997 to $500 million in 2000, and could reach $10 billion by 2010.

Such activity must be seen in the context of the situation in the USA, where the chronic diseases of diabetes, cardiovascular disease, respiratory disorders and cancer afflict more than 100 million Americans each year at an annual cost of more than $500 billion in healthcare expenditures and lost productivity.

Back to the UK

After years of refusing to see that US experience was something from which we could benefit, suddenly we had a rash of PCT-based pilots around the country trying out US ideas, and some of the results have been significant. For example, a pilot of active management of conditions at Castlefields Health Centre showed a 15% reduction in admissions for older people and the average length of stay fell by 31%, from 6.2 days to 4.3 days.

This success mirrors that in the US. An evaluation of the Evercare model of case-management for elderly patients found a 50% reduction in unplanned admissions, without detriment to health. There was a significant reduction in medications, with benefits to health and a 97% family and carer satisfaction rate and high physician satisfaction.

Similarly, US provider Kaiser Permanente has, for example, an average length of stay of just four days for patients recovering from hip replacement surgery. This is in part due to their management of chronic disease, facilitated by greater integration between generalist and specialist care.

The realisation that such improvement are possible and the existence of the other drivers shown schematically in the Figure, the UK disease management horizon is about to be transformed.

The putative CDM Public Service Agreement should set out what the government expects to be achieved and provide a very firm incentive to get things done. This will be part of the 2004 Spending Revue and thus effects should be seen in the short-term.

The PSA will be boosted by the forthcoming Long-term Conditions National Service Framework, to be implemented in 2005, and no doubt by both the new five-year NHS Plan, which will take over from its 2000 predecessor, and the Public Health consultation.

Further, the emphasis on shifting care from the secondary to the primary sector will help disease management since it will remove much of the necessity to work across the primary/secondary boundary where communication can be slow, costly and not good for patients.

So is this Nirvana?

By no means. Not even nirvanaesque. But it is on the right road.

Take co-ordination and communication. These imply a joined-up and interconnected service that just doesn’t exist. Further, there are few private companies able to deliver appropriate IT solutions to include coverage of the home-based patient and their carers, and to provide data to all. Although following the pilot schemes there is the start of an appreciation about the level of joint working that is necessary, to get this spread country-wide will require a huge investment of resources with a massive education programme.

Then consider the question of self-care. The Expert Patient programme is a start but there is a long way to go in a service that has a tradition of discouraging the patient from taking too much responsibility.

What will Happen in the NHS?

Particularly the PSA will force the NHS to take disease management of chronic conditions seriously and, because the infrastructure and services are not in place, it will be forced to look to US experience and to buy in know-how, consultancy and both IT and care-based services.

The rumoured scrapping of the public/private Concordat will produce fierce competition amongst the commercial sector, but it could deliver some cost-effective deals for the NHS.

As more services move into the community, the tension between PCTs and the acute sector will increase. That could lead in time to yet another major restructuring process, but this time for very good reasons. The end result would have to be a more joined-up service, but that is another story.

What is in it for Industry and the Private Care Sector?

The scope is well beyond what would have seen possible when the Concordat was set up by Alan Milburn, but in a much more aggressively commercial atmosphere.

The NHS has the task of transforming itself very quickly into the biggest disease management organisation in the world. If the Department of Health is plugged into the vision outlined above then the £15 billion figure reported by Clinica as the cost of programmes to buy in medico-technical services, begins to intellectually hang together.

PCTs will have to buy services focused on integration and communication, and will have to provide their patients with self-care education, service and back-ups. Many appropriate self-care products do not exist. Thus there is great scope to do business.

The pharmaceutical companies have the resources and the knowledge to play a major role in product and care provision, and they should find it easy to import US know-how. Pfizer seems to have stolen a march in Haringey, but providing the rest get their act together quickly, there should be enough for all.

Since success can’t come too soon for the government, they will be very supportive of initiatives and the added commercial attraction is that the opportunity is now. If the whole vision comes together we shall all benefit.

The Local Delivery Plans of PCTs have many references to Chronic Disease Management. A typical example:

Modernising Health and Care Services – Sunderland PCT Local Delivery Plan 2003/2006

We have set up a new Modernisation and Reform Group to look at services for those with chronic illness. This year we will be focusing on the following services:
· Diabetes - implementing the priorities and standards set out in the National Service Framework.
· Chronic Pain - to review the chronic pain service at City Hospitals Sunderland and ensure its continuity.
· Respiratory Disease - developing support services to improve community care and avoid the necessity for admissions to hospital.
· Brain Injury - we will be considering the development of a local integrated service for people with traumatic brain injury.