The Other Side3:

Interview with a Senior Ward Sister

On Target asked Ann Green, Senior Sister at the Clinical Decisions Unit, Solihull Hospital, about her perspective on the healthcare industry and its sales force.

What types of healthcare product do you purchase?

Disposables such as urine bottles and bedpans, plastics such as syringes, needles, IV equipment and O2 equipment. Pressurerelieving equipment. Peripherals for monitoring equipment and hoists. The ordering system means I have to get ‘non-stock’ orders signed off by my line manager. I can order what I like from the NHS supplies catalogue as long as I come in on budget at the end of the year – which I have never managed to do in 15 years.

How often do you meet representatives selling medical equipment, wound care products and so on?

Approximately monthly. Sometimes at my instigation: right now I’m working with a couple of representatives on the equipment we use for certain methods of blood sampling. The drive for this is infection control rather than financial. I’ll feed the outcome back to the Infection Control team and hope the Trust adopts the product. However, it will be an addition rather than a replacement product, and there will be no funding to support it to the best of my knowledge.

I have been known to switch off listening to the sales patter and count how many times my name was used…

How helpful are the healthcare representatives you meet? How aware are they of your clinical and financial priorities?

Usually they are extremely helpful, especially in terms of providing on-site training. They’ll come along to talk to a group of staff, and will usually provide sandwiches (especially when we advise them how close we are to M&S). The ones who come as part of a Trust initiative are usually briefed on what the objective is. For example, we have recently changed the brand of cannula dressing we use, so the representative came along more as a courtesy visit than anything else. I don’t think he liked the fact that I told him I thought his product was inferior to the one that we currently use, but I’m sure he’ll get over it.

What do you like about representative visits? What do you dislike?

I like being able to pick their brains about the product and find out what’s new. I like the training, the free pens, tourniquets and Post-Its (though I have an internal grumble about how these impact on the product costs and the global stranglehold of the big companies), and the M&S grub.

It’s good when you form a relationship with a representative whose product you use and trust. These relationships are characterised by a willingness to educate and inform, often a trial of whatever it is, responsiveness to e-mails and phone calls, and no hard sell.

I don’t like overtrained representatives who clumsily use techniques such as the overuse of my name – I have been known to switch off listening to the sales patter and count how many times my name was used. I think the worst example was a dressings representative. I had already told him I would have a limited need for his product, and that should I need any of his hugely expensive (albeit effective) silver dressings I would get them from Pharmacy on a named patient basis. This matters because then they come off the drugs budget and not my non-stock budget. He did a lunchtime seminar which I attended along with my Pharmacist colleague Rachael. Having worn my name out, he clearly realised who held the purse-strings for a wider area, and I think the ‘Rachael counter’ hit 12 or 13 while the ‘Ann counter’ had tumbleweed around it.

I don’t like it when representatives won’t deviate from their sales patter to talk to me in terms of what I want from them. I also think it is an utter discourtesy to turn up without an appointment, and I will only see them if I am interested in their product and I have the time (a rare combination). I don’t like it when I tell them I am not available and they still attempt to ‘put a foot in the door’.

The worst sin is demanding to have an audience when we are extremely busy. A couple of weeks ago, a representative from a company supplying enteral feeding pumps turned up and was clearly very put out because I refused to see him. The Trust had arranged for him to visit all the wards but hadn’t told us, and I was already trying to do ten jobs at once. I never needed to know how the previous unit worked, so I wasn’t particularly desperate to find out how the new one worked either.

What new medical technology have you found most valuable in recent years?

Non-invasive monitoring equipment, probably; almost all temperature and blood pressure recordings are now done electronically.

It’s good when you form a relationship with a representative whose product you use and trust. These relationships are characterised by a willingness to educate and inform.

Advances in pressure relieving equipment means that we don’t see the horrible pressure sores that were only too common and frequently killed patients years ago. Expensive equipment is still only as good as the person operating it, and there is sometimes a tendency for nurses to use things without critically analysing and assessing what they want it to achieve.

What new medical technology are you most looking forward to in the future?

I’d quite like to get my hands on more of the stuff that’s around now but is simply not affordable: we could do with a handheld bladder scanner, for instance. Actually, I’d like to see more of the simple technology that makes sharps injuries to staff less likely; again, it’s around but is considerably more expensive than what we currently use.

 

 

 

The ‘vital spark’ of enthusiasm for selling is what makes the difference between a successful sales professional and a hard-working loser. Mark Edwards looks at how the spark can be rekindled.

Acandidate for a healthcare sales position has just left the interview room. The panel look at each other. The candidate looks good on paper. The recruitment consultant keeps ringing to say how great this candidate is. But something is missing. The panel agree that the candidate has an excellent CV; has sound experience in the right therapy area; gave a strong example of competitive selling… There is a long pause. Then someone says: “Just not enough enthusiasm.” The panel look at each other, and their heads nod enthusiastically – as if to underline the consensus on what this person lacks.

The challenge faced by the unenthused at work is that they do not have positive associations with their work activities.

Enthusiasm sells. Not only does it bring a presentation or detail to life, it is the fuel that drives a representative through the challenges of the job. An enthusiastic sales person will deliver on both quantitative and qualitative measures. An unenthusiastic sales person will fail on at least one count, and possibly on both. The number of calls will be affected as the desire to make a call is reduced – and if access is given, an unenthusiastic greeting and detail has negative consequences.

The thrill is gone

How many sales people have plenty of capability and experience – and yet fail to make the most of it because they lack an enthusiasm for what they do?

If they have a strong sense of loyalty and responsibility, they will probably be putting in a full day’s work – but putting in the hours in the field and making the calls is not all that is required to be successful in sales. Making a dutiful effort while lacking in enthusiasm can be the source of many problems. In the short term, a lack of enthusiasm can lead to a dip in sales from which one can recover – but in the longer term, it can dry a person out and make the necessary turn-around a tougher experience.

What can you do, as a sales professional or sales manager, to relight the fire? Can enthusiasm be developed? Once lost, can it be regained?

How enthusiasm works

We all have the capacity to be enthusiastic, and to find things for which our enthusiasm flows. Think about something you are enthusiastic about – such as music, sport, films or reading fiction. Whatever enthuses you, it is certain that you have formed a set of positive associations with that activity. You have positive expectations of it, you enjoy the experience and you savour the rewards of engaging in it. But it is far more difficult to be enthusiastic about things that you do not appreciate or enjoy.

As a young boy, I was bitten by a dog. Prior to this event I had quite positive associations with dogs. Afterwards, however, I had a very negative association with the dog in question – and soon, this became a negative association with all dogs. You could put me in a room with the cutest, friendliest dog in the world and I would still be looking for the door. The association is the key. It determines your expectation of an event – and so affects your thinking, attitude and behaviour. The challenge faced by the unenthused at work is that they do not have positive associations with their work activities. Over time, their field experiences and their thoughts about those experiences have become muted, dulled or even negative. Going to work has become a chore.

Yes, this person will still get up in the morning and go out to do a day’s work in the field (because of a sense of obligation or a need for security). However, they will do so with a heavy heart and a negative expectation. This is transmuted into an apathetic approach to the tasks in hand. The lack of engagement leads to an average experience (at best), which in turn reinforces the negative associations. Remember: enthusiasm is all about positive expectancy and association.

Changing mental habits

So how can enthusiasm be developed, trained or regained? The answer lies in developing a positive association between ourselves and our work.

For those who have lost the ‘fire’, it is about unlearning what they have learned. I do not advocate a Pollyanna approach whereby everything is spun positively, but this is unlikely to be a danger for the unenthused. Lack of enthusiasm tends to colour one’s thinking, and pessimism and cynicism prevail. Seeing things negatively becomes the norm. It becomes second nature to see why something will not work.

For enthusiasm to return, a new way of thinking is needed. Experiences (both positive and negative) need to be considered in a way that is conducive to positive association and constructive learning.

Perhaps the best work on the effective use of this type of cognitive tool is Learned Optimism by Dr Martin Seligman. He links optimism and pessimism with specific ‘explanatory styles’. Your explanatory style is the manner in which you habitually explain to yourself why and how events happen. It is the ‘open secret’ of a positive outlook. An optimistic explanatory style spreads personal enthusiasm, whereas a pessimistic explanatory style dulls it.

For example, suppose a representative fails to gain access to a targeted surgeon when trying to sell a medical device. How do they explain why? They might think:

• I am no good.
• I’m not good at selling.
• It wasn’t my lucky day.
• The surgeon was prejudiced against me.
• This surgeon doesn’t like reps.
• I wasn’t feeling very well.
• The surgeon was having a bad day.
• I didn’t have time to prepare for the call.

Seligman found these explanations could be rated along three dimensions: personalisation (internal vs. external), pervasiveness (specific vs. universal) and permanence (temporary vs. permanent).

He found that the most pessimistic explanatory style is correlated with the greatest lack of enthusiasm. The response “I am no good” can be classified as internal, universal and permanent. It conveys a sense of discouragement and despair.

After gaining access to a hard-to-see doctor, the depressive would say “I was lucky”, whereas the optimist would say “I am good at this.”

A more optimistic person would blame someone or something else – for example, by saying “The surgeon was having a bad day.” The most optimistic explanatory style is external, specific and temporary. Conversely, for a good event, the explanatory style is reversed. After gaining access to a hard-to-see NHS professional, the depressive would say “I was lucky”, whereas the optimist would say “I am good at this.”

The breath of life

For enthusiasm to be developed, trained or regained, these cognitive tools need to be applied. Remember, you cannot do this to anyone. We can only do it to ourselves.

So before teaching the appropriate cognitive tools, we (as trainers) work to develop the necessary awareness, responsibility and desire to change. With these in place, the cognitive toolkit can be taken up and applied. The results soon follow.

Success is not always immediate or fixed, since old habits are hard to break. Regular reviews and top-up sessions help to keep the momentum going, and eventually the desired turn-around is achieved: enthusiasm is regained!

References

Learned Optimism, 1990, Martin Seligman PhD PILOT – Personal Development, 1999, D.M. Edwards

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Mark Edwards is the Founder and Managing Director of Mpower Development Ltd, a leading provider of sales capability and performance culture programmes to the pharmaceutical, IT and telecoms industries. He can be, and should be, contacted on 020 7477 6570 or at mark@mpower-dev.co.uk

 

 

 

Reporting problems

with medical devices:

How the representative can help

MHRA’s Clive Bray explains the Agency’s adverse incident reporting system for medical devices and how sales professionals can help safeguard public heath.

The Medicines and Healthcare products Regulatory Agency (MHRA) is the executive agency of the Department of Health charged with protecting and promoting public health and patient safety by ensuring that medicines, healthcare products and medical equipment meet appropriate standards of safety, quality, performance and effectiveness, and that they are used safely. One way it aims to achieve this is by investigating reports of adverse incidents involving medical devices and instigating corrective actions to reduce the risk of recurrence.

What is an adverse incident?

An adverse incident is an event that causes, or has the potential to cause, unexpected or unwanted effects involving the safety of device users or other persons.

Most manufacturers and suppliers capture feedback on their products. If they don’t, they should pay urgent attention to putting an efficient system in place. This will form part of each company’s post-market surveillance system, which should include identifying and capturing relevant data on adverse incidents at an early stage.

Medical device sales professionals are among those closest to the customer. They need to be aware of and facilitate the reporting of adverse incidents to MHRA or other persons.

What leads to an adverse incident?

Causes of adverse incidents involving devices may include:

• design or manufacture problems
• inadequate servicing and maintenance
• unsuitable storage and use conditions
• selection of an incorrect device for the purpose
• inappropriate management procedures
• poor user instructions or training.

Adverse incidents may also be caused by the conditions of use, such as:

• environmental conditions (e.g electromagnetic interference)
• location (e.g devices designed for hospitals may be unsuitable for a community setting).

Why reporting is vital

Any adverse incident involving a device should be reported to MHRA. Some incidents could lead to:

• death or life-threatening illness/injury
• the necessity for medical or surgical intervention
• hospitalisation or prolongation of existing hospitalisation
• unreliable test results and risk of misdiagnosis or inappropriate treatment.

Ongoing faults that maintenance visits have failed to rectify should also be reported, as should other safety or quality problems. These can help demonstrate trends or highlight manufacturing inadequacies. Reports of adverse incidents that appear to be caused by human error are also helpful, since the error may be due to deficiencies in the design of the device or the instructions for use.

Making a report

Reports can be made by a variety of means: online, e-mail, fax, telephone. Online reports may be submitted via the MHRA website or NHSNet at any time. Reporters are routinely kept informed of the progress of the incident investigation and given a summary of the conclusions.

In some cases, investigation reveals the need to communicate device safety advice to users and patients. Medical Device Alerts (MDAs) are the prime means of informing medical device users in healthcare and social care. MDAs warn of particular problems and risks, and recommend appropriate action to minimise them. MDAs are distributed to all NHS trusts and primary care trusts in England via an electronic system (SABS).

On Target Quick Read

• An adverse incident is an event that causes unwanted effects involving the safety of device users. • In 2005, MHRA received 7862 adverse incident reports on medical devices. 2.8% involved a fatality and 10.7% led to serious injury. • Sales professionals are close to the customer and play a vital role in reporting adverse incidents. • Representatives should familiarise themselves with their company’s systems and provide feedback on how these can be improved. • Sales professionals should encourage purchasers and practitioners to report incidents to MHRA.

What can go wrong?

MHRA is concerned with preventing the occurrence of adverse incidents, not with assigning blame or liability. It investigates incidents carefully and objectively to prevent similar incidents occurring elsewhere.

No medical device should ever be considered 100% safe. Constant effort is therefore required to reduce both the rate at which adverse incidents occur and the severity of the outcome. Reporting adverse incidents to MHRA provides valuable information that can help to prevent similar incidents from happening again. The information provided to the Agency helps to build up a picture of what is happening with medical devices across the UK. This is supplemented by reports from around the world. All of this information is regularly reviewed to identify trends.

Experience suggests that although user error may contribute to the cause of many incidents, there are often underlying factors that have influenced the user’s actions. These may be related to the design of the device, or inadequacies in the instructions for use, the management and maintenance of the device, or user training.

MHRA welcomes receipt of all incident reports – even where user error has already been identified as the likely cause. A one-off incident in one health establishment, when combined with information on several other incidents, may point to a need for local action or action by the manufacturer.

Taking action

MHRA can act in a variety of ways to prevent the occurrence of incidents. It may initiate enforcement measures, or monitor action taken by manufacturers to make devices safe. It may remove them from the market.

Equally, it can issue national warnings and recommendations for action to healthcare professionals, or inform relevant authorities in other EU member states.

In 2005, MHRA received 7862 adverse incident reports on medical devices. 2.8% of these involved a fatality and 10.7% a serious injury. 25.5% of the reports prompted ‘in-depth’ MHRA investigations. The Agency published a wide range of advice to healthcare professionals and other users, including 72 MDAs that recommended appropriate actions to minimise the recurrence of the problem. These measures are a major contribution to improving the safety of devices in use.

How you can help

Sales staff can play an important role in the post-market surveillance of medical devices. You can help in several ways:

• Familiarise yourself with your company’s systems for capturing adverse incidents.
• Identify potential adverse incidents at an early stage, and ensure rapid communication to company individuals who report them to MHRA.
• Provide constructive feedback on your own systems.
• Ensure your customers are aware of product safety information concerning your products, and that recommended actions are taken.
• Encourage purchasers to report adverse events, either to you, to your company or to MHRA.

Further information about adverse reporting incidents, online incident reporting facilities and downloadable report forms are available from the MHRA website http://www.mhra.gov.uk

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Clive Bray is Director of Device Technology & Safety at the Medicines and Healthcare products Regulatory Agency (MHRA).

 

 

 

The new Collaborative Procurement Hubs provide a structure for integrated hospital purchasing. Medtech companies now have the opportunity to work with the hubs to co-ordinate regional healthcare provision.

Hospital purchasing in the UK is increasingly dependent on coordinated regional strategies that achieve consistent provision, planned use of resources and economies of scale. The NHS established three pathfinder Collaborative Procurement Hubs to deliver collaborative working, offering a regional procurement focus and a strong clinical interface to deliver the right products and services for the local health economy. They are already proving successful.

The three NHS procurement hubs set up in the West Midlands recently agreed to join forces to form the West Midlands SHA Collaborative Procurement Hub. This is in line with the DH’s strategic plan to implement one hub per Strategic Health Authority by the end of 2007/8. The new organisation, headquartered in Birmingham, is expected to be fully operational by 1 October 2006. It will set standards for best practice that will be replicated at other Collaborative Procurement Hubs based within each SHA area throughout the UK.

Challenges and benefits

The challenging new targets set by the Government, coupled with the reorganisation of the NHS, are impacting directly on the healthcare market and how companies conduct business with Acute and Primary Care Trusts. It is vital for the industry to understand these new challenges.

One of the new targets, to slash patients’ treatment times, will have an enormous impact on working practices. By 31 December 2008, the time taken from GP referral to completion of treatment must be cut from 82 to 18 weeks. This means there will have to be significant changes in the supply chain, with just-in-time processes becoming essential. Still more importantly, there is a drive to ensure that more products and services are obtained from local businesses within each region. This will have a direct effect on the many small and medium-sized companies producing medical and health technology across the UK.

For example, Medilink West Midlands, a regional network for medical and healthcare companies, works actively with hundreds of local businesses – offering them business support and helping them to find commercial opportunities. It also works with a number of key NHS partners, one of which is HPC.

Local networks, national systems

With plans already in place to streamline and rework the procurement process, MedilinkWM is offering medtech companies in the region (and interested professionals nationwide) an opportunity to understand more about the route to market via the HPC.

The seminar ‘Working with a Collaborative Procurement Hub’ on 21 September (see below) provides a unique opportunity for local businesses to find out more about HPC: what it is, why they should use it, what it can and cannot do, and why they should engage with a hub. It will provide guidelines on how the hub interacts with other organisations, and the best ways to present products or services to clinical experts.

HPC hopes to build strong links with local companies to ensure supply-chain sustainability. Instead of having to meet individual consultants from many different hospitals, local businesses will be able to go to HPC, who will evaluate the product on behalf of the hospitals and trusts they represent. This will enable the company to reduce the cost of bringing its product to market, which will benefit local hospitals and the community.

Presented by NHS procurement professionals, the seminar will introduce local companies to the relevant procurement routes, access points and collaboration opportunities, and give them an opportunity to put their questions to the experts. It will also illuminate the bigger picture: the new structure of healthcare procurement.

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Working with a Collaborative Procurement Hub’ takes place on Thursday 21 September from 8.30–13.00 at Wolverhampton Science Park. If you are interested in attending, please book online at http://www.medilinkwm.co.uk via the Events Page. For more information, please contact Barbara Wild, Events Manager at MedilinkWM, on 0121 452 5630.

 

 

 

Paul Midgley, Director of the Healthcare Partnership, reviews the current state of Practice-Based Commissioning and service redesign in England, and looks at how this will affect companies selling medical equipment.

Earlier this summer, On Target discussed the changes in the English NHS arising from Payment by Results and Practice-Based Commissioning (PBC). Since Anita Baylis’s article appeared in June, implementation of these reforms has gathered pace, and we are now able to see some early indications that PBC groups are planning rapid changes to care pathways – which will affect your sales.

In essence, PBC is a way of engaging local GPs and other care providers to take on more of a role in reducing the need for expensive hospital care, and to provide a wider choice of local (and cheaper) alternative services.

This article examines the early trends and identifies key areas of care where changes are occurring. It also challenges healthcare companies to work as partners with the new commissioners in primary care in order to ensure that they are kept ‘in the loop’ as new pathways and providers arise to develop services.

PBC – the background

The deadline for practice engagement in PBC, set for the PCTs by the Government, is the end of 2006. Implementation has been assisted by the inclusion of an ‘Enhanced Service’ payment in the revised GMS contract, which came into force in April 2006 and applies to all GP practices. This will pay out 95p per patient to practices on production of a PCT-approved PBC business plan, and another 95p per patient in April 2007 for achieving the plan objectives. Given that an averagesized GP practice has nearly 6000 patients, this engagement in the ‘towards PBC’ enhanced service should net practices around £11,500 of additional funds. If there is one thing the Government has learnt about GPs, it is that they respond more positively to a challenge when there is a carrot attached.

A further carrot to engage GPs in PBC is the prospect of practices (or commissioning groups of practices) being able to retain (for reinvestment into services) 70% of any cost savings they are able to make against indicative budgets set by the PCT. These indicative budgets cover the full range of clinical activity costed under the Payment by Results scheme (using 2006–7 PbR tariff prices). These indicative budgets can amount to several hundred pounds per patient, as they take in all prescribing costs and almost all hospital treatment that patients are referred to by GPs.

So an average-sized practice under PBC will have stewardship (on behalf of the PCT) of an indicative budget of around £3m. Savings can only be redistributed to the practice if the local PCT is not in financial deficit. In the case of PCT deficit, the PCT’s statutory duty is first to break even and then to redistribute savings.

Progress to date

A recent survey by the National Health Intelligence Service (www.nhis.info) of 250 Primary Care Trusts looked at progress with PBC, clustering and service redesign. It identified 190 PCTs where PBC ‘clusters’ of practices had formed, and 141 where topics for service redesign or clinical focus were identified in their business plans. The deadline for full engagement in PBC is still some months away, a number of PCTs are in serious financial deficit (though clever use of PBC may be a way out of this), and many PCTs are currently undergoing major structural reorganisations.

These factors may account for the lack of PBC engagement, as other priorities have taken precedence. But by the end of this year, all PCTs will be expected to have engaged practices in PBC to some extent, whether the practices choose to take on an indicative budget alone or as part of a PBC group. Thus we can learn a good deal by examining the 141 ‘trailblazer’ PCTs in more detail.

You must keep your ear to the ground to know who and where your customers are.

The NHIS survey has revealed some interesting information about service redesign intentions, which to some extent overlap with the service redesign themes identified as ‘quick wins’ in the DH PBC guidelines issued to PCTs and practices in February 2006 (see ‘Practice based commissioning – early wins and top tips’, www.dh.gov.uk). The DH’s PBC ‘quick win’ areas are chronic obstructive pulmonary disease (COPD), dermatology, heart failure, long-term conditions, mental health, ophthalmology, orthopaedics, podiatry and urology.

Of particular value in the NHIS survey is the knowledge of where specific projects are already under way. Armed with this knowledge, you can engage with stakeholders in these pilot areas – and by working with these groups across primary and secondary care, help customers in other areas who have not started on the redesign route and are potential key customers in areas of high product usage. The top service redesign themes (with the % of PCTs redesigning the service) from the survey are shown below.

It is unsurprising that reducing unplanned emergency admissions is number 2 in this chart. 60% of the cost of all hospital care comes from patients admitted to hospital as emergencies (i.e. by ambulance, without a GP referral), particularly outside normal surgery hours.

Top service redesign themes

Dermatology (54%) Reducing unplanned emergency admissions (43%) Diabetes/insulin conversion (31%) Orthopaedics and trauma, COPD, ENT (26%) Gynaecology/obstetrics (22%) Cardiology/heart failure, ophthalmology, musculoskeletal (20%) Diagnostics (18%) Prescribing, referral management (17%) Minor surgery, urology (15%) Anticoagulation services (14%) Long-term conditions (11%) Mental health, sexual health, general surgery (10%)

The number of clinical pathways being redesigned per PCT varies (in this sample of 141 PCTs) from 32 in Bournemouth to 1 in Herefordshire and Hillingdon. The average number of pathways being redesigned is 5.5. A list of the top PCTs in terms of the number of clinical areas being redesigned is shown on the left.

Top PCTs

Bournemouth 32 Doncaster Central 21 Carlisle and District,East Yorkshire 18 Sutton and Merton 16 Nottingham City,Southend on Sea 15 Castle Point and Rochford,Eastern Cheshire, Hammersmith and Fulham, Shropshire County 13 Broadland, Cheshire West 12 Ealing, Richmond and Twickenham, Tower Hamlets 11

Lessons of a PBC pioneer

A typical example of a PCT already engaged in PBC and service redesign is Gedling PCT, located north-east of Nottingham, serving a population of around 100,000 patients. It needs to make 5% savings to break even over 2006–7. Its chosen areas of focus include: reducing emergency admissions; cardiology/heart failure (provision of community heart failure nurses); providing a dermatology GPSI service in a local LIFT health centre; mental health (investment in counselling services); orthopaedics and trauma (using a GPSI to triage orthopaedic referrals and treat in the community whenever possible); pain management (local pain clinics in the LIFT building, reducing waiting time vs. local university hospital, reducing costs); rheumatology (see O+T above); sexual health (developing local expertise among nurses to avoid waiting times in the overstretched secondary care service); minor surgery (through existing local enhanced services).

If you don’t understand how your customers and their operating environment are changing, you run the risk of not taking up opportunities for partnership working and growth – and then losing out as your competitors take up the challenge.

A number of challenges face the Gedling PBC cluster in addition to the PCT deficit. In November 2006, Gedling PCT will be subsumed by Nottinghamshire PCT. Clinical engagement in PBC at individual GP and practice level has been slow, due to the lack of any major financial incentives offered to cover GP and manager time away from the surgery while carrying out the necessary redesign work (which is a major undertaking). Additional factors include the merger of the two major hospitals in Nottingham, which could reduce patient choice, and a lack of drive from local clinical leaders among the GP workforce. In Gedling, most of the drive for PBC pathway redesign has come from the PCT, which is motivated by the need to make savings to offset its financial deficit.

In Gedling, both the soft tissue and the dermatology GPSI service redesigns have been protracted from initial setup to implementation – particularly the latter stage, where one GP had to start dermatology GPSI training from scratch. Such time delays in GPSI training raises the possibility of ‘quick wins’ through the re-siting of existing specialists (at least for part of their time) from their secondary care bases into primary care facilities such as LIFT premises (e.g. for outpatient clinics). Those of you with long memories may remember that a similar shift of provision happened under GP fundholding between 1992 and 1997.

Additional capacity

As well as using ‘Practitioners with a Special Interest’ (PwSI) such as extended skilled GPs, it is also likely that PBC commissioners will source the provision of additional ‘secondary care’ services from private providers (e.g. Diagnostic & Treatment Centres), hospital consultants working in chambers (in their non-NHS time) and, increasingly, social enterprise providers (e.g. patient support groups) where existing services are inadequate, and where the alternative provider can meet the required tariff price and quality considerations (as assessed by the PCT).

The focus for the new, larger PCTs, in their role as commissioners, is to assess the needs of the population and commission appropriate (additional) services to meet these needs within budget. This means that existing PCTprovided services will eventually be sold off to other organisations (by 2008, according to ‘Commissioning a Patient-Led NHS’, DH July 2005). We are already seeing this with PCT-led GP surgeries, which are being put out to tender and taken over by a variety of organisations, from neighbouring practices to multinational corporations (e.g. United Health Europe) – and indeed, recent press headlines have greeted the appearance of tender invitations in the Journal of the European Union for businesses to take on the running of a number of NHS provider functions.

Commissioning, provision or both?

GPs have been quick to observe that certain secondary care clinical procedures or packages are currently attractively priced under the PbR tariff, and are within their skill set to perform outside hospital. This is already leading to certain groups of practices coming together to provide services beyond the scope of their existing GMS or PMS contracts where they have the necessary skills and premises.

Practices or groups wishing to set up as providers may do so under an Alternative Primary Medical Services (APMS) or Specialist Personal Medical Services (SPMS) organisation structure, or through the more traditional company models such as Company Limited by Guarantee, Company Limited by Shares (both private and public) and Limited Liability Partnerships. A good example of such a group is in Epsom, Surrey, where Epsom Downs Integrated Care Services (EDICS Ltd) has a contract with Epson PCT to provide a number of additional (secondary care type) services under an SPMS contract. Many GPs in Epsom are both members of the local PBC commissioning group and shareholders in EDICS Ltd, which has its own facility to provide surgical and diagnostic services.

So the Government has really opened up opportunities for entrepreneurial primary care practitioners and other private providers to reshape both commissioning and provision of services, and to break the traditional monopoly of the major hospitals. In response to this increasing competition, five years from now we can expect all hospitals to have Foundation Trust status and be providing services not only within the hospital but in a variety of community settings – which means you must keep your ear to the ground to know who and where your customers are.

Quality Assured Patient Pathways

As commissioners, it is the primary duty of PCTs to ensure that new providers meet the strict quality and governance standards to become approved providers (and earn a place in the ‘Choose and Book’ referrals booking system now operating in GP practices).

A recent publication by the Royal College of General Practitioners aims to help new primary care based commissioners focus on quality – which, given the financial imperative of cost savings, is critical to ensure that the additional capacity is as good as the existing (secondary care based) services and not just a cheap substitute. Current secondary care providers may take heart from this document, as it shows that the new providers have a huge amount of work to do in order to prove that they are capable of commissioning quality-assured services.

The whole process of service redesign, from conception to delivery, can take well over a year. Already busy GPs will tackle service redesign in a highly-focused, prioritised way, looking for as much assistance as possible. The sting in the tail for secondary care providers is that PCT commissioners will also be more stringent in applying these quality tests to existing providers, which may require some trusts to raise their game.

Recommended Steps

Overall needs, requirements and analysis •Service design idea •Evidence for change •Stakeholder involvement Service redesign •Redesign themes Contracting and implementation process •Introduction of change •Service specification and implementation Evaluation •Pathway provider performance •Care location and environment •Access to care Governance •Corporate governance and probity

The recommended steps – some of which you may be able to help PCTs with – are shown on the right.

How medical equipment companies can help

Many of the new commissioners in PBC groups, and many new providers, are only now developing the skills required to effect the necessary changes – conducting health needs assessments, writing business cases, etc – and could benefit from the expertise in these areas that companies such as yours can provide.

The NHS in England is undergoing a transformation that may change what your customers do and where and how they do it, especially in the hospital sector and especially if your therapy area is one of those highlighted in the NHIS report (see above). If you don’t understand how your customers and their operating environment are changing, you run the risk of not taking up opportunities for partnership working and growth – and then losing out as your competitors take up the challenge.

If your company has these skills in-house and has an interest in the therapy areas undergoing redesign, there is a great opportunity for you to approach the new commissioners and providers and work together to build new primary care based pathways of healthcare. If you do not have the skills and knowledge to assist your customers, make sure that you identify a partner organisation to guide you and ensure that you make the most of these opportunities.

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If you would like to know more about the range of training and support services that the Healthcare Partnership provides to PBC commissioning groups, and to healthcare companies supplying the NHS, please contact Paul Midgley on 0870 2413506 or enquiries@healthcarepartnership.com

 

 

 

for the IVD sector!

Doris-Ann Williams, Director-General of the British In Vitro Diagnostics Association (BIVDA), explains the key role that the diagnostics industry plays in healthcare in the UK – and asks why the Government seems unable to diagnose its own failure to give this vital industry its due.

In recent years, the word ‘diagnostics’ has been used increasingly often in Government policies and targets for healthcare. But what does it mean – what are these ‘diagnostics’?

Broadly, they fall into two main areas: in vivo and in vitro diagnostics. The literal meanings of these terms are ‘in life’ and ‘in glass’ respectively. In vivo tests are done to a person’s body – for example, X-rays, imaging and scans – whereas in vitro tests are performed on samples of body fluid or tissue taken from the body. In vitro diagnostics are more commonly known as IVDs, and this sector is the focus of this article.



IVDs are the tests used to diagnose illnesses, monitor therapy and screen for disease in the population. They are also used to ensure the safety of the blood supply for transfusions by screening for infectious diseases such as HIV or hepatitis. IVDs produce information to help healthcare professionals decide what actions to take when treating patients.

IVDs: value for money

The last year has been a very busy period for the UK in vitro diagnostic sector. The market has continued to grow, with UK sales for 2005 of £447 million. On the face of it, this seems an enormous amount: a 6% increase on the sales figure for 2004, when sales were £420 million – clearly above the level of inflation. But first of all, consider that this is all the clinical sales, including the consumables that diabetics use to self-monitor their blood glucose levels, as well as all the screening tests for the blood supply. Then you need to be aware that hospital laboratories saw their workloads from primary care increase in 2005 by up to 25% – but their budgets to run their services remained the same as the previous year.

Now think about the variety of tests the total sales figure encompasses, with input into virtually every patient treated by the NHS, and compare it with an NHS expenditure of £895 million on statins alone in 2005. That’s practically twice as much spent on one type of drug alone as on the whole of IVDs. You will begin to realise two points:

1. The NHS gets tremendous value for money from the IVD sector. 2. The financial margins for the IVD industry are tighter than ever before.

Pathology services cost less than 3% of the NHS budget, and of this only 20% is represented by the spend on supplies.

Increasingly, tests are performed outside the laboratory, since portable equipment that can be used after simple training has become widely available. This is more expensive on a cost per test basis, but when other factors are included it can prove a more cost-effective solution – especially for primary care.

This means that the sales methods for this sector are changing, with companies having to demonstrate cost-effectiveness rather than purely clinical utility and technical specifications. Marketing the products also requires more sophistication in helping laboratory managers to produce a business case for a budget increase to pay for upgrading technology or introduce new tests into their services.

In short supply

Meanwhile, back in the NHS, we are all aware that we are facing a cash crisis – the newspapers have been covering this heavily over the past few months, but the problem has been evident for much longer. Hence the introduction by the Department of Health of a group to focus on getting better value for money (or, to paraphrase, even lower prices) from suppliers under an initiative known as the Supply Chain Excellence Programme (SCEP).



As a sector, we took this fully on board – we were truly SCEPtical! The first ‘wave’ did not include pathology supplies, but it had a devastating effect on other supply sectors such as wound dressings. So you can imagine the concern that BIVDA and IVD companies felt when it was announced that pathology supplies would be included in the second ‘wave’ of product categories last summer.

The supply of pathology products to the NHS has become very complex. The purchasing methods have also increased in sophistication, with suppliers finding innovative solutions in order to provide equipment with minimal capital outlay – automated systems can now cost six-figure sums! The latest model is heading towards complete managed services for all hospital laboratory services within one Trust (but often covering more than one site). These are huge projects for suppliers and customers alike, and their details are beyond the scope of this article.

This complexity of supply helped with SCEP, however. It became clear to the Department of Health that pathology would be ‘very hard to do’ – and just at this point, in November 2005, Health Minister Lord Warner announced an independent review of pathology services to be led by Lord Carter of Coles. This enabled the Department to remove pathology supplies from wave 2 of SCEP, as it was expected that consideration of the cost of supplies would be included by the review panel.

What is BIVDA?

Association (BIVDA) was established in London in February 1992 as the national trade association for companies with major involvement and interest in the In Vitro Diagnostics (IVD) industry. BIVDA represents the interests of the IVD industry in the UK at the European Diagnostics Manufacturers Association (EDMA), which in turn represents the IVD industry in Europe – particularly at the Commission, as the evolution to the Single Market progresses. In addition to its regulatory support function on behalf of its members, BIVDA pursues a strategy in the UK of raising awareness of the clinical and cost utility of diagnostics in the provision of effective healthcare. The membership of BIVDA currently represents over 90% of the industry. These members decide the general policy of BIVDA at its Annual General Assembly. BIVDA is governed by an Executive Committee of company representatives, elected from the membership along with its Director-General. It assumes responsibility for formulating policy and planning activities and services. Day-to-day management is handled by a full-time secretariat based in Central London. BIVDA represents both manufacturers and distributors who are active in the UK. Therefore it is not just an association of UK diagnostic companies. All IVD companies, irrespective of their national origin, are eligible to become members and to nominate individuals for office.

The timelines for the review were very tight, and the report was due to be published in Spring 2006. The review team travelled widely in the UK and overseas, looking at different models for pathology services in both the public and the private sector, while at the same time inviting responses from interested third parties – I believe they received more than 100 of these!

Certainly BIVDA supplied a full response to the team, supplemented with meetings and additional information. The key elements for the industry in BIVDA’s recommendations were the introduction of reimbursement for each test (which would allow more rapid uptake of new technology); appropriate levels of evidence to support cost-effectiveness; and proximity of testing to patients – this is a patient-centred service.

On Target Quick Read

• Diagnostics fall into two areas. In vivo tests are performed on the living body. In vitro tests are performed on blood or tissue samples. • In vitro diagnostics are commonly known as IVDs. • In 2005, UK IVD sales grew by 6% to £447 million. This represents a low amount when compared to investment in other health services. The NHS spent £895 million on statins alone in 2005. • Sales methods for the sector are changing. Clinical decisions are being made based on cost-effectiveness as well as clinical effectiveness. • The Supply Chain Excellence Programme (SCEP) has been introduced to focus on ensuring value for money from suppliers. • The second wave of the SCEP initiative was due to include pathology services, but an independent review of pathology services has replaced it. • The long-delayed review includes BIVDA’s recommendations for the modernisation of pathology services..

Tried and tested

All of this activity took us up to the end of April. So what is happening now?

• Across the sector, there was concern about unpaid invoices (at that point more than £50 million was overdue).
• Individual trusts are starting initiatives to put more pressure on NHS suppliers to reduce their prices further – and even asking for retrospective discounts.
• There is a separate ongoing move to reduce the reimbursement of blood glucose testing strips by 15% from August, which could have a potentially devastating effect on the IVD industry and diabetic patient services alike. (See the news report in the July issue of On Target, page 5.)
• The DH report ‘Reforming Pathology Around the Patient’, based on the Carter review, was finally published on 2nd August. It includes BIDVA’s recommendations in its proposals for the modernisation of pathology services (see above).

So this year has been a testing time for the IVD industry – but the public affairs and media campaigns that have been running have highlighted the use of diagnostics, and the professionals who run these services, at high levels of Government and within the media. This can only be good news for a sector whose products, used appropriately, can offer savings to the NHS through earlier diagnosis and correct therapy.

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Doris-Ann Williams is Director-General of the British In Vitro Diagnostics Association. For more details on BIVDA, see www.bivda.co.uk