The roads to market

by Admin 1. October 2008 11:41

In the second of our series of interviews on healthcare market access, Katy Draper of Marketing Medicine discusses how medtech companies can successfully negotiate the NHS procurement system.

Nothing divides the medtech industry like the question: Is the NHS a worthwhile market for UK companies? The case against the NHS is well known: it’s a slow adopter, with approval and procurement processes that demand a lot from companies in terms of time and commitment. On the other hand, many UK medtech companies – and not just the larger ones – are building successful business relationships with the rapidly-changing NHS, which has declared itself open to partnership and eager to support innovation.

Katy Draper, a healthcare marketing consultant with experience of helping medtech SMEs to engage with the domestic market, discusses why the NHS is important for the UK medtech industry and what companies can do to break down the barriers. She argues that, like any relationship, the commercial understanding between medtech and the NHS requires give and take on both sides – and that as communication improves, both partners have everything to gain from working together.

Is the NHS an important market for UK medtech companies? If so, why?

It’s important to crack the NHS market if we can because it’s our home market. There are clear benefits to companies in selling to local customers. Also, it gives the UK public access to innovative new medical products developed here. The UK population will clearly benefit from having this extra high-quality product available to them – and it keeps money within the UK economy, providing employment. There are several high-profile cases of products and drugs not being made available within the NHS; the debate goes on, balancing scarce resources to the needs of an ever more demanding and ageing public.

However, it’s a balance: healthcare is a global business, but if you’re based in the UK, it’s a great shame not to do business with the NHS. I think the NHS could be higher on companies’ agendas, but I do understand the commercial pressure forcing companies into markets that can be penetrated more easily.

Because of ongoing developments in NHS procurement, and all the emerging Government agencies that companies have to deal with, it can appear a highly complex structure to have to navigate around – and that puts a lot of UK companies off. The level of complexity required also varies between products.

Procurement regulations for medical products and services are essentially the same across Europe, but for some reason the system is perceived to be more complicated in the UK. Of course, companies might think: If I export to other countries with less restrictive access and perhaps even larger market potential, then I can grow quicker and easier. It’s critical for a new company to ensure positive cash flow, and if you’re managing a business that’s a major issue.

The NHS could be a more important market for many UK companies if they were able to devote more time to learning how to navigate its processes. I have come across a few organisations that gave up at the fi rst hurdle with NHS procurement – I don’t accept that defeatist view, but I do recognise that the NHS is quite hard to get into. Work is needed to break down the barriers on both sides.

“It’s important to crack the NHS market if we can because it’s our home market. There are clear benefi ts to companies in selling to local customers. Also, it gives the UK public access to innovative new medical products developed here.”

For example, we recently completed a project with a company where we needed to find information about products in a particular devices category to be included in a forthcoming tender, so we contacted the supplies agency – we got quite a frosty response, and were passed back and forth between agencies. It was time-consuming and frustrating simply trying to find the right people to speak with. If you’re in that situation and you need to get money in for the shareholders, I can see why companies would opt for an easier solution.

As a healthcare consumer it concerns me that other parts of the world are leaving us behind, with new technologies being more easily adopted overseas. But we need to be cracking this problem and working in closer partnership with the NHS. I know that industry bodies are working hard, but it tends to be the larger companies that are members of the main groups, and I don’t know how much of the support and information permeates to the SMEs. That won’t happen overnight.

How can medtech SMEs in the UK best gain access to the complex and elusive NHS procurement system?

They need to invest time and effort in finding out how it works. Businesses need to put resource into managing procurement: understanding how the tender processes work and developing appropriate relationships. You need people in your team who can navigate their way through the system: account managers with the skills and breadth to negotiate with different stakeholders.

European procurement legislation asks businesses to prove that they are safe, reliable and robust and that they can deliver the work required. Tenders have always been competitive, with commercial pressure to prove merit and value for money. In theory the processes should be easier now, as things are transparent and feedback should be offered as best practice. Companies need to improve the presentation of their tenders, putting all the information together in the way the NHS wants it.

As a marketer who believes that the customer is king, I was disappointed recently to learn that nobody from ‘industry’ had gone to the NHS Confederation – me included! To me, that’s potentially a poor reflection of the industry’s perspective of the NHS as a customer.

What are the most important contact points within the NHS structure for such companies to aim at?

The most crucial body to understand is the NHS Purchasing and Supply Agency. Companies need to know how NHS PaSA works and how it fits into the rest of the NHS, and understand its role as the overarching body that provides guidance and manages procurement.

“It’s a time of opportunity – and fortune will favour those companies that are brave and innovative and take the time to understand the NHS, work with it and help it through the development process.”

You have three different levels below that. The first is NHS Supply Chain, which manages national framework agreements and overseas procurement. It works closely with the procurement hubs and Trusts. It’s crucial to understand how the Supply Chain works, establish a relationship with the team managing your product group and know well in advance when tenders for your products are coming up. There’s a lot of helpful information on the NHS SC website, which is worth looking at.

There are also the massive regional procurement hubs that have been set up to buy products at a more local level. These have their own procurement and mini-tender agreements. They can purchase under the national framework agreements that have been made by NHS PaSA and the Supply Chain, or they can set up their own procurement systems. Examples of these hubs are Procurement North East and the Healthcare Purchasing Consortium (HPC) in the West Midlands.

Individual Trusts have their own supplies department and local contracts managers. They buy small quantities of product for local hospitals. If a surgeon wants to use a particular medical device that’s not on the national framework, they would go to the Trust to buy that. In primary care you have the Drug Tariff, which includes a supplies list for medical devices in the community – if you want to sell your products in the community, they ideally should be listed on this tariff. However, some PCTs are developing relationships with suppliers directly.

Another key thing to be aware of is that hospitals are becoming much more e-aware, so you may need to have an e-commerce strategy. Businesses need to be on SID, the Suppliers Information Database. You can place all your policy documents and procedures up there and keep them up to date. Getting on there doesn’t necessarily mean you’ll get business, but companies need to have a presence there. Then there’s the e-Catalogue, where the NHS puts things it has purchased through the framework agreements. If you have a contract, you need to make sure you are appropriately represented there.

There may be other potential ports of call such as the PCT Commissioners and the Centre for Evidence Based Purchasing. Then there are the clinical trials, ethics committees, local formularies… the list goes on and on!

So there are lots of different agencies and bodies you may need to be involved with, depending on your products – and that’s even without sending your team in to speak to the clinicians, nurses, physiotherapists or whoever the end user of your products may be. It’s all very well getting a product listed, but you also need people out there getting the products through the system at a local level.

How can these companies go on to build sustainable commercial relationships, or even partnerships, with the NHS?

That’s where it’s really becoming more exciting. The NHS is certainly facing up to more grown-up business relationships, and the secret is for companies to be in tune with that: to find out who the key NHS customers are and really work at communicating with them. It’s a time of opportunity – and fortune will favour those companies that are brave and innovative and take the time to understand the NHS, work with it and help it through the development process.

Companies need to buy into the NHS’s agenda of innovation and quality of care, of giving patients and clinicians more choice and more of a say. They need to take all of that on board and work with it, understand it, live it and breathe it. It’s no longer just a case of getting a product in there and pushing it through. It’s all about communication.

I don’t think the NHS will be able to deliver everything that the UK population demands over the next 20 years without partnership with industry. Truly sustainable partnerships only happen when both parties win. I think strong industry leadership is required to help us understand our evolving customer, with high-profile examples of ‘best practice’ to inspire and guide us.

What does Lord Darzi’s Next Stage Review mean for the NHS as a purchaser of medical technologies?

There are good messages in the Darzi review for medtech businesses. Clearly, much space is devoted to the recognition that the NHS is falling behind as an innovator and adopter of new technology. This is a huge step forwards. To improve, the NHS needs to work at making things easier for small, innovative businesses.

Though the NHS says it’s open to smaller businesses, it can be incredibly daunting and off-putting when tender evaluation criteria score the size and longevity of the company, pitching you against large blue-chip multinationals. The NHS needs to be more realistic about the criteria it uses in selecting companies: if it wants innovative new businesses to come through and take products forward, it will have to work more closely at putting its own new measures of ‘innovation’ into tender evaluations.

Industry and the NHS are still some way apart, but there are signs that the gap may be narrowing. Groups such as the MedTech Cluster Opportunity Group in the West Midlands are bringing industry and the NHS together, building firm relationships and setting up exciting initiatives. In the same region, MedilinkWM has helped small businesses to engage with the HPC, who have been very helpful. These are hopeful signs for the future.

Katy Draper

 

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Medtech Features

The pharmaceutical industry and community pharmacy - a better way of working?

by Admin 1. October 2008 05:00

Deborah Evans and Michael Holden look at how the role of the community pharmacist will change as part of the White Paper’s vision for pharmacy, and how this will create new opportunities for partnership working with the pharma industry.

Over the last three years much has changed that has impacted and continues to impact on community pharmacy in England and the pharmaceutical industry (See box 1). These provide both opportunities and challenges for community pharmacy as it realises its full potential within the primary healthcare team. Overcoming these challenges, managing the change, dealing with the insecurities and threats and optimising the opportunities is being met with varying degrees of success by the NHS, industry and pharmacies. The model is moving away from just medication supply to one that increasingly involves the delivery of clinical services.

These provide both opportunities and challenges for community pharmacy as it realises its full potential within the primary healthcare team. Overcoming these challenges, managing the change, dealing with the insecurities and threats and optimising the opportunities is being met with varying degrees of success by the NHS, industry and pharmacies. The model is moving away from just medication supply to one that increasingly involves the delivery of clinical services.

As a consequence of the Pharmacy White Paper (Pharmacy in England - building on strengths, delivering the future), published April 2008, the pharmacy contract in England is now undergoing a review to meet future needs and deliver more quality markers.

Needs

As the NHS moves away from provision and further towards a commissioning role, the roadmap for pharmacy is becoming clearer; it needs to be, and be seen to be, a clinical profession providing quality healthcare services. Financial and distribution changes related to medicine supply have created some tensions between the industry and community pharmacy over recent years.

We must acknowledge that new operating models are here to stay in some form or other, and community pharmacy needs the support of the industry to manage the change, overcome skill and knowledge gaps, support service development and facilitate effective engagement and integration with other primary care providers and commissioners.

The traditional product model for the industry is changing to product-plus-service as financial balance-driven medicines management strategies and evidence based prescribing impacts on turnover and competitive position in the market. Companies are looking for additional strategies to grow and protect their portfolios.

To achieve a win-win, all parties need to identify and address each other’s needs through effective partnership working.

Opportunities

The White Paper highlights pharmacy’s significant place in the NHS, and while the focus is mainly on community pharmacy, its context is wider, including hospital pharmacy, professional regulation and education and training. The vision is one of an enhanced clinical role for community pharmacists as providers of new patient services including case finding, long-term condition support, medicines management and prescribing, plus the improved delivery of existing services like health awareness, self care and compliance support from ‘Healthy Living Centres’.

The White Paper also seeks to:
• improve access to medicines and promote their safe and effective use
• increase implementation of repeat dispensing to deliver benefits to all
• reduce medicines waste through improved management and compliance
• overcome the challenges associated with accessing medicines out of hours
• improve access in rural areas, e.g. Dispensing Doctors may be able to sell OTC medicines
• establish information exchange between secondary and primary care interface
• commission services for the safe delivery of oral chemotherapy
• embed safe medicines practice in primary care to reduce unplanned hospital admissions.

Medicines Use Reviews (MURs) remain a high priority area for the NHS with improvements in service quality and targeted therapy areas based on local health needs. Peer review, Continuing Professional Development, research, audit and decommissioning of MURs from those failing to meet quality standards are all recommended in the White Paper.

Change is essential

Community pharmacy will need to change both culturally and operationally to provide additional patient value, whilst delivering excellence and consistency in services. It will need to:
• be repositioned, recognised and valued by all as healthy living centres
• change the business model to an expanded range of patient clinical services
• deliver the core supply role safely, consistently and efficiently
• adopt legislative changes to deploy the whole pharmacy workforce
• improve inter-professional relationships, particularly with GPs
• have access to Summary Care Records
• electronically capture interventions and use new technologies
• be more focused on measurable quality outcomes
• build on professional, clinical and leadership competencies to deliver services.

What does this mean for industry?

Partnership working, where engagement and outcomes deliver benefits for both parties whilst complying with regulations, guidelines and governance arrangements is the solution; making this happen is the challenge.
• Pharmacy services will increasingly impact on the choice of and compliance with treatment, delivering improved health outcomes and reduced unplanned attendances and admissions.
• Pharmacy will be more actively engaged in the early identification of long-term conditions through integrated screening and risk assessment programmes with an associated increase in pharmacotherapy interventions for these new patients in line with national and local guidelines.
• Extended public health initiatives including smoking cessation, weight management and sexual health services may involve appropriate provision of Prescription Only Medicines.

What should you consider?

• Recognise pharmacy as a key health professional and enabler of improved adherence to medicines; ensure pharmacy is a key customer in national and local plans.
• Support the development, implementation and evaluation of patient services to create the evidence base for commissioning of other services.
• Facilitate multidisciplinary relationships, particularly with GPs, to optimise patient care.
• Work with national and local pharmacy bodies to support clinical development and develop implementation skills, including project management, patient communication and behavioural change (e.g. Motivational Interviewing).
• Ensure that your knowledge of pharmacy is current and credible.

What do you need to know?

• How well do I understand this customer, their needs and how I might add value?
• How long will the full integration into primary care take and which of my customers are moving fastest?
• What services are likely to be commissioned locally? Are these relevant to my portfolio and what value can pharmacies add to the target patient group?
• interdependencies within the local primary care team and how might I add value?
• What are the clinical training needs for pharmacy in my product area and how might I support continuing professional development?
• How many patients on my medicines are not complying with their treatment and if they were, what would this mean to their health outcomes and product penetration?
• How can the pharmacist add value to improving compliance with my medicines?
• What role does the pharmacy have in case-finding in diabetes, vascular risk, osteoporosis and COPD and how can I support this?
• What are my competitors doing with pharmacy?

Pharmacy activities to be implemented widely

• Minor Ailments Scheme to be incorporated into contractual framework
• Partnership between pharmacy stop-smoking services and local NHS services
• National template for commissioning of chlamydia screening
• Expand pharmacy-based contraceptive services
• Integral in delivery of the vascular risk assessment programme
• Enhance the role of pharmacy in the care of patients with diabetes
• Support for patients on new treatment for the management of LTCs
• Systems in place to support early detection and prevention of some cancers
• More robust standards and metrics for Essential and Advanced services
• Harmonise accreditation for pharmacists
• Financial incentives for quality innovation with penalties and sanctions for poor performers


For more information:
• Pharmacy in England - building on strengths, delivering the future, Department of Health, April 2008: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_083815
• PSNC summary: www.psnc.org.uk/pages/whitepaper.html
• The contractual framework for community pharmacy in England and Wales 2005: www.psnc.org.uk
• Scottish Pharmacy Contract: http://www.communitypharmacyscotland.org.uk/
• Northern Ireland Community Pharmacy Strategy – Making it Better: www.dhsspsni.gov.uk/makingitbetter.pdf
• Building the Community- Pharmacy Partnership: www.cdhn.org/bcpp/

About the authors: Deborah Evans MRPharmS and Michael Holden MRPharmS run balance, an operating division of The Tipping Point Ltd, which helps community pharmacy, the pharmaceutical industry and NHS commissioners to meet their needs and those of their patients.
www.balancesolutions.org.uk

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Features

Pharmacy and the sales force: a new partnership

by Admin 1. October 2008 05:00

The role of the pharmacist is evolving, and with it, community pharmacy’s importance as a customer of the pharma industry. So what do you need to know about these new healthcare providers?

In the not so distant past a sales call to pharmacy customers was often managed with a few boxes of extra stock, pens or note pads for the assistants and a quick chat about the latest discounts or advertising campaigns. However, changes within the NHS and changing roles for community pharmacists means that sales forces have to develop new strategies to work more effectively in community pharmacy and build mutually beneficial relationships.

Clinical experts on the High Street

Pharmacists are no longer simply dispensers, counting and labelling medicines, but are being actively promoted as readily accessible clinical experts on the High Street. NHS patients are increasingly being encouraged to visit their pharmacist for advice and treatment before requesting an appointment with their GP. Last year, almost one in five patients in a Department of Health survey put their pharmacist as their first choice when seeking information about their long-term condition and almost two-thirds of people with long term conditions who visited their local pharmacist felt encouraged to self care. Therefore, pharmacists are taking greater responsibility for prescribing and disease management in association with patients and GPs. Pharmacists are also influencing medicines usage at a number of levels from medicines use reviews (MURs) through to independent prescribing, which makes them an important audience for pharmaceutical companies and their sales forces.

The vast majority of pharmacists welcome this shift to a more clinical role that allows them to become more engaged with their customers and patients. In the past few years over 1800 pharmacists have undergone additional training to become an independent or supplementary prescriber. Understanding the different levels of clinical engagement of your pharmacist customers is important for pitching your sales or product presentation at the appropriate clinical level and building relationships with a new group of prescribers.

Supplementary prescribers

Supplementary prescribing is a voluntary partnership between the independent prescriber (doctor or dentist) and supplementary prescriber (pharmacist). With the patient’s agreement the prescribers implement a patient-specific clinical management plan (CMP) which enables the pharmacist to prescribe any medicine for the patient that is referred to in the plan until the next review by the doctor or dentist. There is no formulary for supplementary prescribing and no restrictions on the medical conditions that can be managed and the pharmacist has the discretion in the choice of dosage, frequency and product as specified by the CMP.

Independent prescribers

Independent prescribing was introduced in 2006 as a means of improving patient care and choice and access to medicines. Pharmacist independent prescribers can prescribe any licensed medicine for any medical condition that the prescriber is accredited to treat. This includes most medicines in the British National Formulary with the exception of Controlled Drugs.

Special interests

Pharmacists with Special Interests (PhwSI) are pharmacists who deliver a clinical service normally through their pharmacy, beyond the scope of their normal professional role. A PhwSI has to be individually accredited by the primary care trust (PCT) to provide a specific specialist service and they will normally work across a locality or PCT within a clinical network. Although they are not required to qualify as prescribers, as they work closely with GPs and other primary care professionals they play an important role in prescribing decisions. Service areas for PhwSI range from anticoagulation services to the management of long term conditions such as diabetes or asthma.

Pharmacists can also deliver prescribed medication through Patient Group Directions (PGDs) and Minor Ailment Schemes. A little research before you visit a pharmacist for the first time can ensure that you provide the appropriate information at an appropriate level of detail.

Medicines Use Reviews

Compliance is a major issue with medication in the UK and can result in patients not getting the full benefit of a medication as well as drugs being wasted.

MURs are an Advanced Service within the Pharmacy Contract and consist of accredited pharmacists undertaking structured concordance centred reviews with patients on multiple medicines, particularly those receiving medicines for long term conditions. The review is intended to help patients understand their treatment and identify any problems they are experiencing along with possible solutions to enable patients with LTCs to manage their condition better. A report of the review is provided to the patient and to their GP. Some pharma companies offer tools to assist pharmacists in carrying out such reviews.

Medicines Use Reviews and Prescription Intervention Services represent an opportunity for pharmacists to improve the service they offer patients and generate additional income. Such reviews also offer pharma companies and sales reps an opportunity to support pharmacists and discuss your products – benefits, interactions etc.

Role of education and training

Top tips for sales reps

Raj Patel, superintendent pharmacist at Mount Elgon Pharmacy in London offers his tips to sales reps to ensure a successful call:
• It may be obvious but do make an appointment to see the pharmacist and their staff. If you haven’t met them before find out their name before you visit.
• Make sure you’re on time – allow plenty of time to find a parking spot, particularly in city centre pharmacies. If you’re delayed or have to cancel always phone to let the pharmacist know.
• Keep up to date on changes within pharmacy – those driven by the profession, by government, by local primary care priorities and by consumers – and use your knowledge to identify opportunities for the pharmacist and your company.
• Be aware of the priorities of local primary care organisations (PCO) and whether these offer opportunities for you and your pharmacist customers.
• Understand what pharmacists and their staff need in terms of marketing support materials and training. Ask for feedback on materials and pass it back to head office.
• Know if your pharmacist is a prescriber or has a Special Interest, so you can pitch your discussion at the appropriate level.
• Recognise that pharmacists are healthcare professionals as well as business men and women, so presentations based purely on commercial benefits are unlikely to have as much impact as ones that integrate the professional and commercial aspects.
• Respect the fact that pharmacists have little time to spare, so keep your presentations short and to the point.
• Be polite to counter staff and always leave the door open to come back again.
• Be smartly dressed – they will be!
Developing all the new pharmaceutical services proposed by the government in community pharmacies will require trained pharmacists and adequate remuneration will be a key factor in determining where and how pharmacists do this training.

Pharmacy staff will also require training to supervise certain aspects of the dispensing and supply of medicines which will help free up pharmacists to use their clinical skills to better effect, e.g. carrying out MURs, and to improve the range of services available in the pharmacy. The changes in the pharmacist supervision requirements also provide opportunities for pharmacy staff to develop their skills.

Although there are ambitious plans for pharmacies and the services they could offer in the future, you will appreciate from visiting busy pharmacies that most pharmacists are already overstretched with dispensing and the other obligations of running a business and staff management. Another concern for pharmacists is how such new services will be funded, particularly as their NHS income has already been effectively cut by Category M changes in the Drug Tariff.

Pharma companies are ideally placed to offer some support to pharmacists in their new roles. Through development of training materials, sponsorship of equipment and even remuneration for specific MURs, pharma companies could find themselves in the advantageous position of having a key input into emerging practitioners, which would then have positive effects on brand awareness and recommendation. By asking your pharmacists what support you or your company could provide to enable them to carry out these new services, you will build a stronger relationship and perhaps grow your category and brand share.

If you are introducing new product lines or switching a product from POM to P, make sure that your pharmacists and their staff are fully prepared for launch. Many pharmacists find it helpful to have training materials for new products or initiatives presented in brief face-to- face seminars as staff have the opportunity to ask questions.

Share your knowledge and expertise of sales and marketing with your customers. If you are aware of initiatives or promotions that have worked well for other pharmacy customers, discuss with your pharmacist how they could introduce or implement similar changes or training programmes. Television or press advertising drives customers into pharmacies so make sure you give advance notice of campaigns and their key messages.

Fawz Farhan and Paul Lowndes are directors of Mediapharm, a marketing communications consultancy specialising in pharmacy education. Mediapharm produce Pharmacy Insight, a free monthly report for marketeers on pharmacy and the new opportunities for pharma companies.You can subscribe at www.mediapharm.co.uk.

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Features

Pharmacy in action

by Admin 1. October 2008 05:00

The following are just a few examples of how the work of community pharmacists is expanding across the UK.

Local coagulation testing in Essex

Contact: Surinder Singh Kalsi, Pharmacist, Kalsi Pharmacy, Barking

The service: When the local PCT was inviting bids for an anti-coagulation drugs monitoring service, Community Pharmacist Surinder Singh Kalsi put in his bid in collaboration with two GPs. They won the bid and started the service in March 2007.

Why was it needed?
Anti-coagulation monitoring was previously carried out in hospital clinics, but there were frequent problems with GPs not getting results sent through, as well as patients finding it difficult to make the clinic times. Patients on anticoagulant medication need frequent blood tests, often weekly, and not turning up for an appointment can have serious consequences for their health. “We offer patients convenient, flexible appointment times, six days a week. We also run two lunchtime clinics in LIFT (Local Improvement Finance Trust) centres and two further clinics in GP surgeries, which will soon include a third clinic. We’re also doing home visits for those patients who are not mobile,” says Surinder.

Positive feedback: The most recent patient evaluation survey received a 97% satisfaction rate. Patients particularly praise the convenient appointment times, speedy service and efficiency of the system. The GPs are happy too. “Before we took over the service, GPs used to complain that results were not passed on from the hospital clinics quickly enough, or sometimes not sent at all. We send a report to the patient’s GP immediately after each testing and this helps to ensure the patient’s condition is kept stable,” explains Surinder. “We now get invited to the PCT cluster meetings and this gives us the opportunity to air our case in front of the decision makers. GPs are now contacting me for advice on their patients in terms of antibiotic prescribing and choice of other treatment options for other conditions too.”

Prescribing better patient care in Devon

Contact: Karen Acott, Superintendent Pharmacist and Partner, Wallingbrook Health Centre, Chumleigh, Devon

The role: Karen Acott is the fi rst pharmacist to become a partner in a GP practice. “We have a lot of elderly people in our area for whom access to a pharmacy is difficult, so we have a dispensary set up at the surgery,” says Karen. “The GPs were spending a lot of time on medicines reviews which didn’t make the best use of their skills and time. It made sense to have a pharmacist on board to do this for them.”

How it works: All the patients in the practice who are on repeat medication have a medication review once a year. “The doctors still do the more complex medicine reviews such as for cancer patients or mental health patients, but otherwise the doctors will refer any patients with medication queries or problems to me,” explains Karen. “The doctors will often call on me to give advice on medicines queries they have and I also get most of the pain control referrals as this is my specialist area.” Karen also runs a weekly diabetes and epilepsy clinic and briefs the doctors on the latest drugs studies and new National Institute of Health and Clinical Excellence (NICE) medication recommendations.

Breaking new ground: “I think pharmacists should be using their specialist skills in a variety of environments and I’d like to see more of them taking steps to qualify as independent prescribers and use these skills,” says Karen. “I’m often called to give advice to other independent prescribers across the country and invited to participate in Governmentled focus groups, which is really worthwhile as I’m able to give them a realistic and hands-on view of what pharmacists can contribute to the health service.”

Keeping patients out of hospital

Contact: Pam Grant, Medicines Management Pharmacist, Bournemouth and Poole PCT

The problem: Many older people with long-term conditions such as Parkinson’s, type II diabetes and Alzheimer’s have problems taking their medication correctly and the result of this can be hospital admission or moving into a care home.

The solution: In 2002, Pam Grant started developing a medicines management support scheme in Poole. The scheme was designed to help vulnerable patients avoid a hospital stay and remain independent for longer. In 2004 she put a business case to her PCT, presenting data which showed that one in six of the patients she helped had avoided hospital admission. The service was set up in 2005, with three part-time technicians supporting her and 29 pharmacies participating in the scheme.

How it works: The medicines team visits each patient that is referred to them and takes over the ordering of their medicines on a 28-day cycle, as well as providing information and advice, which helps ensure better compliance. “For patients who find it difficult to remember which tablet to take and when, we use specially designed blister packs, with the day and date on each blister. For partially sighted patients we also use dispensing devices, which have an alarm that sounds when it’s time for the patient to take their medication. The device is linked to a call centre, so if the patient doesn’t take their medicines, we’re automatically alerted,” explains Pam.

Is the scheme successful?
Data from 2004 and 2006 shows a reduction in emergency admissions to hospital of 18% and 25% respectively among the patients using the service. In 2006/2007, the service made savings of over £25,000 in prescribing costs. The service only needs to prevent a two-day stay in hospital for each patient managed by the team to cover the running costs.

Preventing medication errors and hospital re-admissions

Contacts: Harriet Lewis, Trafford Pharmacy Network, Trafford PCT; Margaret Ledger-Scott, Chief Pharmacist and Clinical Director Medicines Management, Durham and Darlington NHS Foundation Trust

The problem: When patients are discharged from hospital there is a risk of a communications failure between hospital staff and health professionals in the community, which can result in confusion over medication taken in hospital and that taken at home. Two pharmacist-led schemes have helped to overcome these issues.

Faxing medication summaries: When patients are discharged from Trafford General Hospital, a summary of their discharge medication is faxed to the patient’s pharmacist as well as the GP. “We set up the scheme because we found that the discharge summaries sent from hospital to GP weren’t being acted on quickly enough, so changes to a patient’s medication made in hospital weren’t being followed through,” says Harriet Lewis. “This kind of new service helps to establish the position of the community pharmacist within the wider healthcare team. Pharmacists are the last safety point at the end of the patient care line, and they should be included in the communication links across the interface.”

Treatment booklet: At Darlington Memorial Hospital, the pharmacy team has designed a booklet which is given to patients on discharge and records all aspects of hospital treatment received, including medication. Twelve months after initiation of the project, less than 2% of patients who had been discharged from hospital with a booklet had experienced medication errors. Hospital re-admissions were reduced by 71% “Patients using the booklet became more responsible for managing their own healthcare – they understood what their medicines were for, why they were taking them and they queried any changes,” says Margaret. “The booklet does not only record medication but also risk factors, test results etc. – showing our pharmacists now have a more holistic approach to patient care.”

Published with kind permission from the Royal Pharmaceutical Society of Great Britain.
www.rpsgb.org

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Features

Pharma at the crossroads: Choosing the right direction in a changing healthcare world

by Admin 1. October 2008 05:00

An increasingly difficult market environment is forcing pharma to adopt new ways of working, but how will these changes impact sales models and what will this mean for the field force? David Stern and Sophie Lamle of Roland Berger Strategy Consultants investigate.

Times are getting tough for pharmaceutical companies. Whilst financial pressures, regulatory changes and increasingly active stakeholders have already forced pharma firms to rethink their business models, it seems the most demanding times are yet to come. “For the first time in history, it is evident that this industry will have winners and losers,” comments one senior pharma executive.

The recent Roland Berger report, Pharma at the Crossroads – the result of research among senior decision makers in the world’s leading pharmaceutical firms – provides a unique snapshot of the industry’s current thinking.

What has changed?

Pharma managers highlight how market access and reimbursement have become increasingly challenging in recent years.

Historically, if a company wished to access a market, there were three hurdles a drug had to pass; safety, efficacy and manufacturing quality. Now, however, not only has regulation in these areas been tightened, but some markets – especially in Europe – have implemented a fourth hurdle: cost effectiveness.

“There will be a need for all representatives working within a local health economy to work closely together towards the same goal”

Access to markets is becoming highly restricted in some countries by either governments or payors, who are seeking price decreases or increasingly stringent cost benefit analyses. Chart 1 shows our assessment of the healthcare situation in major healthcare markets with arrows indicating the likely direction of change in the future. It can be seen that many markets are becoming increasingly controlled by payors and are moving towards a cost containment model.

These difficulties have led to pharma companies experiencing increasing price pressure, accentuated by the lack of innovative products emerging from the R&D pipeline. NICE in the UK has set the trend in terms of reimbursement, and rationing has become a major element of cost containment. This may mean that not launching a product in certain markets (as already demonstrated in Germany, France and the UK) due to reimbursement issues will become more common. However, not all senior executives see cost containment as a bad thing due to the associated trend for evidence-based medicine: “Provided you have the right data, you can virtually guarantee the market,” comments one manager.

As well as challenges at the national level, regional organisations (e.g. PCTs in the UK) are becoming increasingly prevalent, resulting in fragmented national markets that call for different commercial models to be successful. These regional organisations can have control over local healthcare budgets and care pathways, creating further hurdles for pharma companies to ensure good uptake of a drug.

Our study highlights that only 40% of companies have implemented market access programmes at a country level, 15% at a global/ regional level, with a further 35% still working on these. Given the importance of market access, pharmaceutical managers foresee the need for further investment in these programmes, with the majority looking to improve their organisation, skills and resources (61%) and investing further into stakeholder management (59%).

What does this mean for the industry?

Whilst pharmaceuticals remains one of the most profitable industries, mounting pressure on corporations is affecting the bottom line. Senior executives recognise the need to take action, and are looking to implement cost reduction programmes. Sales and marketing are identified as having the largest cost cutting potential of all business functions, with 5-10% potential savings predicted.

However, not all is doom and gloom. The majority of interviewees consider sales and marketing functions as core competencies for the business, but highlight the need for traditional sales and marketing models to change. These changes are driven not only by the need to reduce costs but also by the recognition that healthcare systems in many countries are changing.

As highlighted earlier, reimbursement and market access are becoming increasingly tough for pharma companies. In countries such as the UK and Germany, organisations such as NICE and IQWIG need to be approached carefully to ensure favourable reimbursement decisions. At a regional level, ‘new’ customers, such as payors and hospital groups, are growing in importance, reducing the influence of the individual physician in many markets. So what is the industry doing to address these issues? How can sales and marketing functions adapt to the new world?

How to ensure market access and increase profitability

We asked pharmaceutical managers to identify the key dimensions of a business model to ensure good market access and profitability in the future.

For market access, executives identify a shift from products towards services and an indirect influence on prescribers as crucial for success. However, most feel that these services would have to be free. This shift to services will lead to interesting collaborations and partnerships between pharmaceutical companies and other bodies, as has already happened with Takeda (see below).

In terms of profitability, senior executives foresee a shift away from individual products to product portfolios; to accounts rather than individual prescribers; and a strong need for flexibility in the field force (including outsourcing). See Chart 2 for further details.

What this means for the UK - partnerships not products

The healthcare market in the UK is in a state of flux. Private providers are able to enter the market more easily, changing the way the NHS has traditionally been run, as exemplified by the introduction of polyclinics.

Increasing cost pressures on the NHS are driving the use of generic products, whilst the power of individual physicians is declining as local organisations such as PCTs create local formularies and care pathways.

Since 2006, the number of PCTs has also fallen, increasing the risk to a pharmaceutical company if relationships with these organisations are mismanaged.

These changes will offer pharma companies an exceptional opportunity for partnership.

The shift towards indirect influences on prescribers has already been occurring for some time in the UK, with some pharma companies looking for innovative partnerships. The majority of major pharma companies already have representatives in place specifically to manage PCTs.

Some have gone even further. For example, Takeda’s view that they could not justify the expense of the large field force required to compete with the big pharma presence saw them invest in only 45 account managers for the UK.

Takeda account managers have been responsible for building relationships with the local healthcare decision makers through partnerships. These partnerships are less about products and more about services, including offers to sponsor nurses, educational meetings and training sessions for the local health community.

Generally there is a growing realisation within NHS organisations that partnership is necessary to ensure the best, most effective care for the population. In addition, new private organisations offer further partnership opportunities for the industry.

The role of the representative

The influence network within local health economies is becoming increasingly complex as these new groups emerge. Exactly who the key influencers are within each local health economy is likely to vary widely by region. Because of this, the need to operate an account management approach is particularly strong in the UK. In future, there will be a need for all representatives working within a local health economy to work closely together towards the same goal. This will require flexibility in terms of roles, skills, team sizes and management.

Due to the important trends in cost containment and evidence-based medicine, representatives are having to become highly skilled in both health economics and the medical science behind drugs. As we move further towards a product portfolio and services approach, the skills of a rep will need to develop even further. How these skills should be spread amongst a field force must be managed carefully and raises further questions for the industry.

Given the increasingly regional fragmentation of the market, pharmaceutical companies will need to differentiate their commercial strategies and tactics according to the specific local requirements, leading to asymmetric organisations and processes. The many additional skills required in the future, as well as new customer groups, growing regional differences and the need for flexibility (including outsourcing) will make field force structures more complex, posing a significant management challenge to UK organisations.

Mapping out the road to future success

Whilst marketing and sales will remain core competencies in the future, they will be differently aligned, with partnerships with external suppliers becoming increasingly important. In the UK, in particular, building a highly skilled field force that can respond quickly and effectively to changing local situations and local customer needs will be the key to future success. What this field force looks like in detail, however, still remains unclear.

David Stern, Managing Partner, and Sophie Lamle, Senior Consultant at Roland Berger Strategy Consultants both have extensive experience of working closely with the UK’s major pharmaceutical companies to redesign commercial organisational structures.

Roland Berger Strategy Consultants, founded in 1967, is one of the world’s leading strategy consultancies. With 36 offices in 25 countries, the company has successful operations in all major international markets. In 2007, it generated more than EUR 600 million in revenues with 2,000 employees. The strategy consultancy is an independent partnership exclusively owned by about 160 Partners.

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Working with Guidelines

by Admin 1. October 2008 05:00

Last month, Ivor Eisenstadt used a specific guideline to show how the industry and the NHS may gain mutual benefit from supporting its implementation. Unfortunately, a Pf layout error caused confusion within the article. Pf apologises for its mistake and this month re-runs this valuable piece.

The recently published NICE guideline on the identification and management of familial hypercholesterolaemia (FH) is summarised below. The guideline recommends that: ‘Healthcare professionals should consider prescribing a high-intensity statin to achieve a recommended reduction in LDL-C concentration of greater than 50% from baseline (that is, LDL-C concentration before treatment).’

Clearly this is an opportunity for those companies marketing statins to support the implementation of the guidance to their own benefit as well as that of healthcare professionals and ultimately patients.

The NICE press release that introduced the guidance quoted Dr Rubin Minhas, General Practitioner and Guideline Development Group chair as saying: “By pulling together the best available evidence and advances in technology with professional and patient expertise, this guideline provides the NHS with a pragmatic and effective blueprint for reducing tens of thousands of deaths from premature heart disease. Only a fraction of people with FH in the UK are identified and the majority of people will remain unaware of their condition and untreated, often with tragic consequences. At the moment, we know that without treatment 50% of men with untreated FH will suffer a heart attack by the age of 50, and 30% of women with untreated FH will suffer a heart attack by the age of 60. Once an individual is diagnosed with FH, the condition can be managed, usually with a statin, to help them reach normal life expectancy.”

NICE provides on-line tools to help healthcare professionals implement its guidelines. National cost reports and local cost templates have been developed to support the implementation of the FH guideline—these are available at www.nice.org.uk/CG071 and are summarised below:
• Costing reports – estimates of the national savings and costs associated with implementation. These are based on assumptions about current practice, and predictions of how it might change following implementation of the guideline.
• Costing templates – spreadsheets that allow individual organisations to estimate the local costs and savings involved. These quickly assess the impact that implementing the guideline may have on local budgets.

What can you do to help?

Support in implementing the guidance can range from straightforward sponsorship of support materials, conferences and workshops that educate and raise awareness of the guidance (as outlined in the previous article in this series) to genuine joint working arrangements.

Such joint working arrangements would need to follow:

• The ABPI Code of Practice
• Best Practice Guidance on joint working between the NHS and pharmaceutical industry and other relevant commercial organisations prepared by the Medicines, Pharmacy and Industry Group and published by the Department of Health (DH) in February 2008.

Ivor Eisenstadt is Managing Director of MGP, the publishers of Guidelines, Guidelines in Practice and Medendium. Its medical education division, Connectmedical, provides opportunities for companies to support healthcare professionals in their pursuit of best practice.

For further details contact Ivor on  01442 876100  01442 876100 or email: ivor.eisenstadt@mgp.ltd.uk

Joint working is defined by the Best Practice Guidance as: ‘situations where, for the benefit of patients, organisations pool skills, experience and/or resources for the joint development and implementation of patient-centred projects and share a commitment to successful delivery’. Joint working differs from sponsorship, where pharmaceutical companies simply provide funds for a specific event or work programme. The DH is actively encouraging such joint working initiatives.

The guidance additionally states that: ‘Joint working between the pharmaceutical industry and the NHS must be for the benefit of patients or the NHS and preserve patient care. Any joint working between the NHS and the pharmaceutical industry should be conducted in an open and transparent manner. All such activities, if properly managed, should be of mutual benefit, with the principal beneficiary being the patient. The length of the arrangement, the potential implications for patients and the NHS, together with the perceived benefits for all parties, should be clearly outlined before entering into any joint working’.

A toolkit on joint working between the NHS and pharmaceutical industry, entitled ‘Moving beyond sponsorship’ was issued to augment this guidance. It focuses on learning from useful examples with a view to recommending and spreading best practice.

Two ‘Good Practice Examples’ featured in the toolkit can be seen above. These are practical examples of the way in which support might be given to implementing the FH guidelines and the principles are transferable across many disease areas. The challenge is to recognise the opportunity that a guideline may present and to work with your local NHS to develop genuine win/ win arrangements that conform to the best practice guidance on joint working.

Familial hypercholesterolaemia – Identification and management of familial hypercholesterolaemia
Guidance type: NICE Clinical Guideline
Date issued: August 2008
Expected review date: TBC

Summary

The advice in the NICE guideline covers the care and treatment of adults and children/young people with familial hypercholesterolaemia (FH) (a specific type of inherited high cholesterol that runs in the family).

Diagnosis

A family history of premature coronary heart disease should always be assessed in a person being considered for a diagnosis of FH. In children at risk of FH because of one affected parent, the following diagnostic tests should be carried out by the age of 10 years or at the earliest opportunity thereafter:
• a DNA test if the family mutation is known
• LDL-C concentration measurement if the family mutation is not known.

Identifying people with FH using cascade testing

Healthcare professionals should offer all people with FH a referral to a specialist with expertise in FH for confirmation of diagnosis and initiation of cascade testing. Cascade testing using a combination of DNA testing and LDL-C concentration measurement is recommended to identify affected relatives of those index individuals with a clinical diagnosis of FH. This should include at least the fi rst- and second- and, when possible, third-degree biological relatives.

Management
Adults
Healthcare professionals should consider prescribing a highintensity statin to achieve a recommended reduction in LDL-C concentration of greater than 50% from baseline (that is, LDL-C concentration before treatment).

Children and young people
Healthcare professionals should offer all children and young people diagnosed with, or being investigated for, a diagnosis of FH a referral to a specialist with expertise in FH in children and young people.
Ashton Leigh and Wigan PCT (ALWPCT) ‘Find and Treat’ Strategy
ALWPCT has a population with one of the lowest life expectancies in England and a high prevalence of coronary heart disease and diabetes. It saw valuable potential to work with industry to find a large cohort of people with these diseases and treat them. It also saw industry as a valuable contributor to its ‘Learning Network’, which aims to deliver high quality continuing professional development to the PCT’s clinical and managerial staff. The Find and Treat strategy involves the PCT working with pharmaceutical companies. A project manager, seconded from industry, has been appointed and is jointly funded by the PCT and ABPI to support the learning network. The pharmaceutical companies are sharing their expertise to support the PCT in the delivery of this innovative project, which aims to decrease morbidity and mortality and increase life expectancy for the people of Wigan. A joint PCT/ABPI Project Board, which reports to both the PCT’s Professional Executive Committee and ABPI’s NHS Task Force, has been set up to oversee development of the Find and Treat Programme and Learning Network Curriculum and overall governance of the working relationship between the PCT and industry.
Nottingham City PCT and the ABPI NHS Outreach Programme: Happy Hearts Project
Nottingham City is the seventh most deprived local authority area in the country and as such its population suffers from associated high incidence of coronary vascular disease. Working in collaboration with six pharmaceutical companies and facilitated by the ABPI NHS Outreach Programme, the parties joined forces to develop and implement a primary care based CVD risk identification programme. Targeted at 13 practices situated in Nottingham City’s most deprived areas, the ‘Happy Hearts’ project aims to reduce levels of CVD risk and associated premature mortality through primary care identification and management of those people at more than a 20% risk of developing diseases such as diabetes, heart disease and stroke. Jointly (and equally) funded by the PCT and the pharmaceutical companies the project has funded the employment and training of 13 Clinical Healthcare Assistants (CHCAs) who will be employed by the practices and, using specially developed software, will identify patients who fit the criteria for potential risk. The patients will be invited to attend a consultation with the CHCA who will conduct relevant clinical tests (BP, blood glucose, cholesterol, etc) and offer appropriate lifestyle advice and support. Patients will be signposted to relevant services such as smoking cessation clinics and, where necessary, appropriate medical intervention via the GP will be offered.

The NHS and the pharmaceutical industry stakeholders have worked together via a joint project board from start to finish, with equal input into all decisions regarding design, implementation and evaluation of the project, and have equal accountability for ensuring desired patient outcomes are achieved.

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