In the first of a new series, Pf’s John Pinching meets Novartis’ Senior Brand Manager and Pf reader, Caroline Armstrong. A franchise coffee house in Farnham sets the scene, as she orders an exotic latte, while he opts for an invigorating Americano (with three sugars).

When I meet Caroline – winner of the prestigious Joint Working Award at the Pf Awards 2012 no less – she exudes confidence, charm and style. Indeed, she immediately draws my attention to a famous local sculpture and points out that, viewed from a certain angle, it resembles something entirely unexpected.  I conclude that it must be ‘attention to detail’, which sets this career-climber apart.

What is your background, Caroline? I come from Newcastle and did a degree in Biomedical Science at the University of Newcastle Upon Tyne. During my time there I worked in a lab at Proctor and Gamble. After approximately five minutes I knew it wasn’t the career for me! I needed to do more than just take microscope slides out of a washing machine for the rest of my life.

How did you embark on a career in the selling side of pharmaceutical drugs?
I attended a recruitment drive, was impressed with the potential opportunities and became a medical sales representative, first at AmDel, then Altana Pharma. I know it’s a cliché, but in order to fulfil my ambitions I had to be out there, ‘carrying the bag’; it’s the best way to build a network and discover how the industry really works.

Do you remember your first gig? Yes, it was pretty nerve-wracking. As soon as I arrived at the surgery, I was taken straight to the GP, without any time to compose myself. It was a steep learning curve, but I soon gained confidence and was able to apply my personality when describing products. Showing your human side in medical sales is vital.

How did that enable you to progress further? I joined Novartis initially as a Vaccine Account Manager, before getting the chance to go on a marketing secondment. I really felt like the company believed in my ability and this ultimately led to my roles as the UK Influenza Brand Manager and Travel Vaccines Senior Brand Manager.

What were the most satisfying aspects of your new Novartis ventures?  Getting involved in really broad campaigns was very exciting. With influenza it’s not just a case of painting patient pictures, you are convincing people to purchase products there and then; sign on the dotted line. From a marketing view, delivering an effective strategy is essential, but from a sales view, you’ve effectively got twenty minutes in front of a healthcare professional to deliver, not just a generic pitch, but one that demonstrates empathy, understanding and confidence in your proposition. There’s only one chance, so you have to make every interaction count.

Does it make you appreciate the impact you’re having on society? It’s pretty amazing to think that last year the number of vaccines given through pharmacy alone could fill St. James’s Park. That really puts the number into perspective.

Do you support Newcastle United, by any chance? Yes, I used to go with my dad, when David Ginola was playing (judging by the wistful expression, I think Caroline may have been a great admirer of the aforementioned Frenchman).

I digress, what programmes are you putting into place in preparation for the dreaded reform act? We have been very passionate about implementing vaccination programmes, which enable a more community-based approach to health. We’re training pharmacists to vaccinate in local pharmacies, enabling many more thousands of people to access healthcare. It will certainly relieve some of the pressure from GPs. People will have the convenience of being able to pick up their weekly shop and a vaccine, all in one place.

How do big companies react to changes enforced by new political policies? From an industry perspective you can’t plan too far in advance because you simply don’t know what the NHS will look like in a few years. If Labour get in all the changes might be reversed and we’ll end up going round in circles.

You’re still young, but seem to have ascended up the ranks rapidly I enjoy what I do and like to do it well; then I’m ready for the next challenge. When you reach milestones in your career it’s so important that you have a story to tell, making sure that it’s as fulfilling and successful as it can be. Some people are satisfied to do the same thing for years, but I want each chapter to represent a new adventure and an opportunity to make a difference.

What does the future hold for you? I’m starting a new job in Basel! (Caroline is making the pilgrimage to Switzerland and she’ll be working as Business Franchise Manager in Novatis’ Ophthalmology business unit – which is nice).

That’ll be incredible Yes, I’m going there with my partner and it will certainly be a great experience. It’s a global role so it will be really interesting to see how other health services, like Australia and Canada, operate compare to ours. I hope they don’t have as many acronyms.

There’ll also be some cultural differences in Switzerland too? Yep, for a start, they only serve wine in 100ml measures and that will take some getting used to!

What will you miss? The higher your position, the greater potential there is for you to be removed from the ‘patient’.  I think I will miss the daily coal face interaction you get when you work in a local market, close to the actual health provision. That is why I think it is so important to remember what it is like when you are on the road, bringing products to life. Ultimately, whether you are in a local or a global role, everything you do is still for the patient.

NHS Cumbria is to re-launch its Cough Cough campaign in September following the success of last year’s project in tackling lung cancer in the region.

Nearly fifty local residents referred for tests were diagnosed with the disease following last year’s campaign – a 61% rise compared to the same period in 2010.

Dr Rebecca Wagstaff, Deputy Director of Public Health, NHS Cumbria, said that long-term survival rates in the region “are not good enough” and it was important residents were encouraged to visit their local GP if they noticed any underlying symptoms.

The campaign aimed to raise awareness of the early signs and symptoms of the disease and the importance of an early diagnosis.

It was developed in partnership with Cumbria’s GPs, cancer nurses,  public health teams and hospital consultants.

Radio adverts, posters, leaflets and high profile advertising, including local residents who have been diagnosed with the disease, will be used again during the campaign.

In 2010, more than 300 people in Cumbria died from the disease. Lung cancer is one of the biggest cancer killers in the UK.

The NHS faces financial risks and worries over organisational success due to the lack of female leaders on Clinical Commissioning Groups, a new report has warned.

Releasing Potential: Women doctors and clinical leadership found women had experienced difficulties joining CCG leadership committees despite evidence showing gender diverse boards improve financial performance.

GP Penny Newman, report author, says the lack of diversity presents “a risk to developing the collaborative and inclusive leadership behaviour needed for organisations to succeed in a complex system”.

The report, funded by the National Leadership Council, was based on in-depth interviews with 26 leading female GPs and consultants with the outcomes tested on a further National Leadership Council workshop which included 43 female medical leaders and other experts.

Several interviewees said they had signalled an intention to take a senior role within CCGs but had experienced issues in joining. Previously, claims had been made of a ‘jobs for boys’ culture from female GPs following a similar study by Pulse. One interviewee even described one leadership committee as consisting of “clubs, gangs and mafia”, insisting there was “exclusion, inequity and disengagement of the rest of the profession”.

Research from the report said that female GPs were more likely to work with marginalised and vulnerable communities and were found to have qualities such as empathy, being able to question and admit vulnerability and offering support and development to others.

“While the number of female doctors continues to rise, there remains an unacceptably small proportion in leadership positions within the NHS,” said Dr Newman.

“Female doctors represent a valuable resource to the health service, both in terms of the style of working and individual talent.

“The NHS needs to enable them to achieve leadership positions through more flexible working and other initiatives to maximise the potential of the workforce and ultimately provide a better service for patients.”

The report follows an investigation by HSJ which revealed that 85% of CCGs were led by men.

 

Pfizer’s Prevenar 13 (Pneumococcal Polysaccharide Conjugate Vaccine [13-valent, Adsorbed]) has been launched in the UK for active immunisation of invasive disease caused by Streptococcus pneumoniae in adults aged 50 and over.

It becomes the first and only pneumococcal conjugate vaccine to be licensed for adults aged 50 and over after gaining a new indication from the EMA.

Dr George Kassianos, GP and immunisation lead for the Royal College of GPs and the British Travel Health Association, says its introduction is an “important achievement and step forward” for adult patients.

The vaccine was first licensed for infants and young children in December 2009 in Europe and used during the UK’s Childhood Immunisation Schedule in April last year.

The new indication provides a new treatment option for the prevention of adult invasive pneumococcal disease (IPD), which includes the potentially fatal bacteraemic pneumonia, meningitis and septicaemia.

Chris Head, CEO of the Meningitis Research Foundation, welcomed the vaccine’s launch in the UK. “The new license for Prevenar 13 provides an opportunity to protect adults over 50, who are more at risk of serious pneumococcal disease than younger adults,” he said.

Until Prevenar 13’s new indication, adults over 65 and those in clinical risk groups were treated with the pneumococcal polysaccharide vaccine. But in clinical trials, patients given Prevenar 13 had significantly higher antibody responses with the vaccine expected to protect against seven out of the most ten most comment serotypes which causes IPD.

Despite the ongoing criticism of the Health Bill as it passes through the House of Lords, structural changes are still happening at ground level. Dr Thoreya Swage outlines the timescale for changes as PCT clusters switch responsibilities to CCGs.

The momentum of reform of the National Health Service in England continues to gather pace. Following a four month hiatus while the wise and the good of the NHS Future Forum pondered and produced recommendations for the adjustment of the Bill, the DH published further guidance on the developing role of the Primary Care Trust (PCT) clusters.

Although the 151 PCTs have been squeezed into fifty-one PCT clusters in preparation for their demise in April 2013, it seems that they have a vital part to play in the development of the emerging Clinical Commissioning Groups (CCGs).

This guidance or ‘shared operating model for PCT clusters’ has been produced by the mandarins at the DH to ensure that the commissioning landscape is as consistent and smooth as possible in time for the takeover by the CCGs. This is so that the nascent NHS Commissioning Board inherits a robust enough system to take account of further developments and improvements in healthcare in early 2013.

 

A shared model

There are six main functions or ways of working for the shared operating model for the clusters. These have been identified where consistency of approach is considered to be of importance and they are listed as commissioning development, financial and operational issues, ensuring quality, emergency planning, development of providers as Foundation Trusts and communications.

 

CCG development

The most important function is the preparation of CCGs for authorisation as soon as possible following the successful passage of the Health Bill through Parliament. The process of authorisation to become fully fledged commissioners is due to begin in the second half of 2012.

Although this is a year away, CCGs can commence their preparations now using a self diagnostic tool – an interactive computer-based assessment that helps them to determine their capability in six domains and identify their development needs.

The areas covered include:

• A clear clinical focus of the CCG commissioning plans to include tackling health inequalities and improving primary care
• Demonstration of meaningful involvement of patients and the wider community
• A plan for development that is clear and credible which, in particular, delivers the QIPP (quality, innovation, productivity and prevention) agenda
• Capacity and capability of the CCG, i.e. robust constitutional and governance arrangements which enable the CCG to commission care effectively and ensure financial control
• Collaborative arrangements for working with other CCGs, local authorities and the NHS Commissioning Board
• Capacity and capability of the CCG leadership which ensures effective working.

The tool helps the CCGs identify priority development areas which form the basis of the developmental plan paving the way to full authorisation.

To support all this work CCGs will receive £2 per head from the PCT clusters as well as extra management resource to help the groups hone their commissioning skills and capability.

CCGs experiencing difficulty in defining their boundaries will have guidance from PCT clusters on how to resolve this. PCT clusters also have the unenviable task of engaging the reluctant practices that so far have not participated in their local CCG discussions, with the aim of being part of a viable commissioning group by October.

 

Separating commissioning functions

All through the last quarter of this year a very detailed exercise is being carried out by PCT clusters to identify and segregate the service areas that CCGs and the NHS Commissioning Board will be responsible for. Although CCGs will be commissioning acute, mental health, community and ambulance care there are other services that PCTs currently commission which will need to be transferred to the Board.

Services such as GP and other primary care contractor groups – primary dental care, pharmacy and optical services – secondary dental care, prison, specialised and military health services are set to go under the umbrella of the NHS Commissioning Board. Even though the contracts for GP services are held by another body, the CCGs are expected to have an input into primary care development and improvement.

 

Quality assurance

A vital component of the commissioning process is ensuring the quality of healthcare. Practices may have been involved to a greater or lesser degree in various quality assurance processes in the past. However, CCGs are required to take on board these responsibilities seriously.

There is a whole raft of procedures and measures including delivery of better health outcomes for patients, meeting the Care Quality Commission (CQC) requirements for safety and quality of services, standard contracts, the NHS Operating Framework, professional guidance and other relevant requirements that CCGs need to get to grips with.

This could potentially be a vulnerable time for the development of the CCGs if attention wanders and serious patient safety incidents are not acted on promptly. Clinical governance processes must therefore be extra secure.

 

Budgets and responsibilities

Over the next year or so there will be a period of dual functioning and handover as the CCGs mature and the PCT clusters delegate more and more responsibilities until April 2013. The handing over of the baton has started now with PCT clusters having identified a “clear percentage of budgets” to CCG pioneers or pathfinders in August and plans for future delegation of budgets set by October.

Sandwiched in between will be the agreement on which mental health and community services will be subject to ‘Any Qualified Provider’ (AQP). This policy is set to be implemented from April next year when GPs can refer to providers of certain services eligible for AQP from a list of approved organisations, including the private sector, drawn up by the DH.

A review of commissioning support required by CCGs has already been undertaken in July with clear arrangements agreed by the end of the year.

In March next year, CCGs will be required to enable the development of the local health and wellbeing boards supported by their PCT clusters – health and wellbeing boards being the mechanism for joint health and social care planning and commissioning locally.

Meanwhile, individual PCTs will continue to carry out their statutory functions through the clusters until their abolition in April 2013. The statutory functions include contract monitoring, ensuring that providers meet their QIPP obligations and other statutory requirements, for example, safeguarding children and vulnerable adults.

The big challenge for CCGs will begin when they will be required to lead the next planning round for 2012/13. This begins in the latter part of this year and is a function previously undertaken by the PCTs.

This will involve doing a needs analysis, identifying local inequalities, understanding demand and activity for local services, negotiating and setting priorities with partners and developing the local strategic vision. Handover of commissioning functions will continue with CCGs being an active participant in the subsequent contract negotiations and agreement.

 

The outside world

It is apparent that despite the pause for reflection on the proposed changes in the NHS earlier this year, the momentum for restructuring and dissolving healthcare organisations continues. The picture remains a little confusing however, as CCGs are in varying stages of development and maturity and it is not clear that all will be truly viable by the tight deadline set for October.

What is clear is that that work of commissioning and delivering healthcare has to go on and now is a good time to find out who the key movers are within the CCGs.

It is at this point in time when the developmental needs of CCGs will be uppermost and it is here that pharma can provide some input. Skills and knowledge in leadership development and highlighting therapeutic areas where evidence-based care really works are two such possibilities.

CCGs will be keen to smooth patient pathways across primary and secondary care and nowhere is this more pertinent than in prescribing effectively. Delegated prescribing budgets are now very real for CCGs and they will be keen to ensure value for money and improvements in care for their patients. This provides a good opportunity for pharma companies to demonstrate the effectiveness of their drugs in specific disease areas.

On the commissioning front, by December of this year, CCGs and PCT clusters will have had to agree what commissioning support they need to carry out this function. Given the requirement to reduce costs, commissioning skills and expertise may actually be thin on the ground within CCGs.

Bearing in mind that effective commissioning will be judged by outcomes achieved as outlined in the NHS Outcomes Framework, pharma is well placed to demonstrate how their products can meet the requirements of domain 1: preventing premature deaths, domain 2: enhancing the quality of life of people with long-term conditions and domain 3: aiding the recovery of people who have an acute illness or injury.

The next few months will be busy while the NHS sorts itself out structurally. Once the picture begins to clear, pharma will need to engage with the new clinically skilled commissioners who now have the financial responsibility for making decisions about healthcare.

Dr Thoreya Swage was formerly an NHS clinician and a senior manager in various NHS organisations covering acute and primary care. She has expertise in commissioning health services and is currently working for a number of NHS organisations, including DH agencies, to develop a more commercial approach to the commissioning of healthcare.

The idea that ‘any qualified provider’ can deliver NHS services may be contentious, but it has roots in existing policy. Thoreya Swage examines the opportunities for industry in the changing health provider landscape.

Successive governments have tried in recent years to shake up the healthcare system in the UK, with England probably being subject to the greatest number of changes. A key element of these shake-ups has been various attempts to expand the healthcare market in order to include the private or independent sector.

This widening of the doorway started in earnest with the deployment of the waiting list initiative in the 1990s, using the spare capacity of independent hospitals to reduce the queues for elective procedures that had built up in the NHS.

The baton was then taken up by the independent sector treatment programme under the last administration: the range of work done by private providers expanded to diagnostic procedures and screening programmes, as well as the construction of bespoke independent hospitals to take on hip, knee and cataract operations from the NHS.

It was at this stage that the concept of patients choosing which healthcare institution to go to for treatment or diagnostic procedures started to take off, with some of those options being in the independent sector. The idea of an ‘any willing provider’ began to take shape, with NHS care being delivered by any appropriate healthcare body as long as it had reached identified quality and safety standards.

However, before the recent change of government this initiative began to cool under external political pressure and at one time even seemed likely to fade away.

What AQP means

Despite opposition, the coalition Government has renewed the ‘any willing provider’ policy, calling it this time ‘any qualified provider’. In July of this year the Department of Health in England issued ‘operational guidance’ to the NHS providing further details to PCT clusters and the emerging Clinical Commissioning Groups (CCGs) – the renamed, modified GP consortia.

This policy has come under the guise of improving the quality of care by widening patient choice for specific services.

The intention is to permit the patient to choose from a list of qualified providers when they require a referral for a specific community or mental health service. To meet the ‘any qualified provider’ (AQP) requirement, a healthcare organisation needs to fulfil the quality, price and contractual obligations for NHS services. This process, as we have seen, is already in place for elective care.

The guidance states that the implementation of AQP will be conducted in phases from April next year. However, some work needs to be done before that. PCT clusters and their associated CCGs need to have decided which community or mental health services they wish to identify for the implementation of AQP locally by October, so that their patients can begin to have access to that care between April and September next year. Three or more services from the following list, drawn up by the DH in conjunction with patient groups, should be identified:

• musculo-skeletal services (neck and back pain)
• audiology services in the community (adults)
• continence care (adults and children)
• diagnostic services (e.g. imaging and heart and lung investigations)
• wheelchair services (children)
• podiatry services
• wound healing and management of leg ulcers
• primary care psychological therapies (adults).

The guidance also says that PCT clusters and CCGs can choose alternative services for AQP in different priority areas if these are supported by local patients – for example, as identified through the shadow health and wellbeing boards (the new joint health and social care joint commissioning boards) – and effective gains in quality and access can be made by doing so.

Getting involved

How can independent provider organisations participate in this process? The principles of the AQP approach are as follows:

• Organisations can qualify and register to provide NHS services as long as they meet NHS assurance requirements.
• Referral pathways and protocols set by CCGs must be accepted by the providers wishing to be on the AQP list.
• Patients are offered a choice of services from the list of qualified providers.
• There will be a fixed price based on a national or local tariff, to ensure that the provider is chosen by quality.

A national qualification process for all AQP providers is currently being developed by the DH in order to minimise bureaucracy and reduce transaction costs. The proposed principles for qualification are that providers:

• must be registered with the Care Quality Commission to demonstrate that they meet the essential standards for quality and safety (or equivalent assurance requirements if providing services not covered by CQC registration)
• are licensed by Monitor (from 2013) so that they are authorised to deliver NHS care
• can meet the terms and conditions of the NHS Standard Contract, including having regard for the NHS Constitution, appropriate guidance and legal obligations
• deliver care at NHS prices
• can meet the service specifications developed by commissioners and comply with referral protocols
• agree with the commissioners on any supporting schedules to the NHS Standard Contract, e.g. on activity levels.

More details of the qualification process will be published this autumn.

The providers that have successfully achieved the national qualification process will be listed in a directory available to GPs later this year.

By November 2011, lead PCT clusters will have produced detailed implementation packs for each service on the AQP list that will include service specifications, contract currencies, tariffs and information models.

It is anticipated that AQP for the services identified above will begin to be implemented from April 2012, with all CCGs having this in place for their patients by September 2012.

What happens next?

AQP will continue to expand: for 2013/14 a further list of services has been identified by the DH for discussion with commissioners, patient groups and providers. The list is not finalised, but will probably include:

• maternity care, e.g. antenatal education and support for breastfeeding
• speech and language therapy
• supporting patients to self-manage long-term conditions
• chemotherapy in the community setting and at home
• primary care psychological therapies for children and adolescents
• wheelchair services (adults).

Opportunities for medtech

The most obvious opportunity for medtech in relation to AQP is in the sphere of direct access diagnostic services, where many investigations such as non-obstetric ultrasound, echocardiography, cardiac physiology, MRI, X-ray, endoscopy and phlebotomy can be provided in the community setting, as indeed some already are (e.g. via Inhealth). These direct referrals can enable GPs to obtain rapid investigations and help to manage their patients in primary care, without having to refer to a hospital consultant.

Another key area is adult hearing services, including audiology and hearing aid fitting. Telehealth and telecare also have a part to play in supporting some of these services by monitoring people with long-term conditions at home. The services identified for the initial phase of AQP have traditionally had poor information systems. Better data collection on activity and health outcomes will be vital for the success of the providers delivering services under this initiative.

The key challenge for medtech companies is to get onto the recognised list of AQP that the DH is drawing up, or to work with partners who will be applying to go onto the list. Rather than regarding independent providers simply as customers, medtech suppliers can work with them to achieve AQP success.

Potential providers need to get up to speed on a number of areas, such as ensuring that they are registered with the CQC, have a good understanding of the standard NHS contract, offer services in keeping with the CCGs’ requirements and can manage within NHS financial envelopes.

The aim should be to identify the lead commissioner(s) within the local PCT cluster and associated CCGs and find out which community services they are planning to include on their local AQP. Alternatively, contacting the local shadow health and wellbeing board (if it is sufficiently developed) may indicate other priority areas for AQP. This is an opportunity for marketing medtech services that can be shown to improve patient care and are aligned with the local health economy’s priorities.

Medtech providers should also be clear about whether they can meet (or help their partner organisations meet) the qualification requirements for AQP. They should look closely at the details of these when they are published by the DH later this year.

Companies should also start doing their homework now on pricing and the care outcomes that can be achieved through their services, bearing in mind that the NHS commissioners will be looking at how the five high-level domains of the NHS Outcomes Framework will be achieved.

Another key milestone to look out for is the implementation packs due in November on service specifications, contract currencies, tariffs and information models. These will require close examination by potential providers seeking to ensure that they are fully prepared for AQP.

Although this initiative seems small in scale it looks set to grow in the future, and further opportunities will present themselves for 2013 and beyond as AQP continues to expand. For more information, visit the Department of Health website.

Dr Thoreya Swage was formerly an NHS clinician and a senior manager in various NHS organisations covering acute and primary care. She has expertise in commissioning health services and is currently working for a number of NHS organisations, including DH agencies, to develop a more commercial approach to the commissioning of healthcare.

How well do you understand the various priorities of a key element of your customer-base: the payer? Omar Ali pens Part II of a typical day in the life of a Formulary Pharmacist.

10AM : GP REFUSED PRESCRIBING OF A PAIN DRUG/ACTION ASAP
OK, we have been here before – this product is non-formulary. It has never been applied for. The GP is well within rights to refuse prescribing. The consultant knows it is non-formulary and has ‘requested’ via a letter – actually stating it is non-formulary, so would the GP kindly prescribe it.

The GP is irate, and the patient is now confused and unhappy: “why wont you prescribe what the expert/consultant has asked for?” There is a stalemate. Not a great scenario – this call is backed up with emails going back with two PCT advisers, a commissioner, a GP and a pain nurse. This will mean going to see the consultant and being firm: these are the rules of engagement, this is the financial framework, this is how I can help you manage your patient.

Thoughts for pharma

We call this ‘lockdown’. It’s a process by which redundancy is built into the formulary processes to ensure compliance, limited loopholes and consequential policing. What’s crazy is I know the brand, and I know the rep. Every month she asks: “when is the next D&T?” I tell her – and nothing happens. Next month, she asks again. So what’s happening?

The representative knows she needs a consultant to bring her brand to the D&T but can’t/won’t affect it. The representative then considers ways around the D&T; KOL to find loopholes, write to the GP, prescribe on FP10(HP), do a non-formulary request, try IFR, etc. In fact, exhaust all opportunities except the one that is needed: D&T approval.

Sometimes the pharma company has a brand philosophy which doesn’t press the right buttons: they have representatives calling the wrong people, the quality of the representative is not good enough, the seniority/decision-making-abilities are lacking.

This ‘lockdown’ effect will usually mean that the company goes round in circles. It focuses on new materials and a wonderfully articulated campaign – usually around ‘Edith’, a 50-year-old patient who is suffering from constipation and can’t enjoy her grandchildren. “If only you would prescribe the brand for her. You would if it was your own grandmother”.

The ‘payer avoidance’ strategy will not work. Lockdown is getting tighter. With Clinical Commissioning Groups it will be even more so. The financial framework will be more akin to trying to prescribe a non-formulary drug whilst working for BUPA, who would neither tolerate nor reimburse because the formulary is under a financial restrictions.

Indeed, the pain market has also intensified. This means numerous brands shouting for a louder voice in an intense market. Neuropathy, Opioids, Fentanyl/breakthrough Ca pain – add these up and you have pharma running around competing for a slice of the pie. Given all the warnings we had with COX-IIs, now we have them with NSAIDS, and of course even the weak Opioids have ‘addictive warnings’ all over them.

It is not surprising we are caught in the headlights of where to go in the name of safety and analgesia. Please someone, be it a brand manager or someone with payer access, see the bigger picture. Help us with the whole pathway. See our needs and work in partnership with us.

11AM : MEETING WITH PHARMA BRAND MANAGER
It’s not often I get a visit from a brand manager! We have been struggling for some time attempting to commission a funding pathway for an osteoporosis product – see earlier Matrix Revolutions. However, we may have a solution now with a variety of process mapping models.

I have finally received a number of options and interestingly the applicable HRG codes for activity within this domain. This has been a headache, despite a NICE TAG within the context of this ongoing saga. A resolution is long overdue. After a lot of liaising and a lot of technical HRG work-up, we may end up up with a streamlined prescribing pathway which lines up the PCT, the GPC, the acute trust, and fracture liaison service.

Thoughts for pharma

There is an intriguing change of paradigm when I am sat having an adult conversation with a brand manager compared to a ‘rep-call’. I realise that brand managers can’t go and see all their customers face-to-face.

But the paradigm shift is palpable. Why? Here we have it: The representative is ‘detailing me’ – that is never going to compare with an adult conversation with a brand manager who gets the bigger picture.

But something else, potentially more devastating: the brand manager is able to vocalise the ‘brand story’ in a far more compelling way than the ‘local rep’. That’s interesting, because the local rep is trained in the ‘brand messages’.

Even if you put aside that the brand manager has a ‘big picture understanding’, the fact that the value of the brand was unbelievably clear means that somewhere along the factory chain of sales force effectiveness and tier upon tier of managers, the message is lost in Chinese whispers. Why? I don’t actually know.

The representatives that are sent to see me are not in the same locator of food chain as I am. In effect, pharma is sending people of a certain authority that doesn’t fit with where I am. Even with account management. Remember, I talk clinical, I talk financial, I do commissioning maps, I do total drug budgets – I still have a boss.

However, pharma send people to see me with the following authority: “I need to get my medic to answer that…I need to get my line-manager to answer that…I need to call in my health economics person to see you…I need to call my regional account manager to approve that…”

When will I see all these people? Why do I need to see them all? Is it all ABPI, is it internal compliance, or is it sales force design? I’m not all for it, but I do see where some industry leaders are coming from in proposing authorised account managers answerable to MDs with budgets run at their own liability and expertise.

I recently did a ‘Payer Process Mapping Day’ for a pharma company/team of Executive Healthcare Development Managers. It fascinated me. Pharma has spoon-fed even higher NHS teams to such a level, that if you clear the playing field and ask them to come up with solutions to landscapes, they go blank. at day, the summarising  suggestions was simply: “we need a toolkit from head-office”. It was worrying. My conclusion?

We need to innovate within the NHS. Pharma companies are stakeholders. We should be asking you to help us innovate, but the people you are sending me… while I’m wanting them to look at the traffic jams I have ahead of me, and help navigate local influencing factors, they are waiting for a tool-kit from head-office!

11.30AM : CARDIOLOGY CONSULTANTS FORUM
Cardiology prescribing has so many focal features right now, I’m struggling to keep up with payer issues. This is due to a mixture of NHS demands, D&T processes, a sizable shift in coronary intervention work – and the drugs required within such units) and recent launches of new products that are proving challenging to implement within our health economy.

The format takes place as follows: I basically ‘gatecrash’ the forum and hijack a section of the agenda to use the opportunity for both information flow – in both directions, buy-in – to various prescribing initiatives, D&T processes and budgetary issues, and input to a number of shared-care-prescribing guidelines.

The aim is to open GPC/CCG cluster prescribing. A lot of this is about supportive communications; managing up – to my Chief and Director of Finance, and managing down – to pharmacy team on formulary policing. I need to take the consultants from ‘one place to another place’ within each micro-managed sub therapy. It’s a give-and-take scenario.

Thoughts for pharma

Cardiology has never really left the ‘priorities’ list. Right now, although there are some exciting and challenging implementations, I foresee a rocky road ahead. Antiplatelets. With the onset of generic clopidogrel’s price suddenly dropping like a stone – Plavix was £40 pcm, generic clopidogrel is now £2.50pcm, the Director of Finance is looking at the cost savings that we have built into our financial planning.

But here’s the catch – not only do we have branded prasugrel, we also now have branded ticagrelor, both pushing upward of £50pcm+. So how do we manage this? I have potential new pipleline antiplatelets which have offerings to interventional cardiology versus a savings plan that I will need to explain if I renege on. Tough. After much consternation, we’d put prasugrel onto our formulary, and now we have displaced this with ticagrelor.

We still have the generic clopidogrel as first line – but we always, always need a second line drug. Interestingly, neither company appears to have come forward with a QIPP line yet. One of them have thought about patient access schemes. NICE looks like it will be happy to support either. Cardiac networks play an important role – the cardiologists just want somewhere else to go after generic failure.

This was a learning curve for me. Whilst the clinical ‘story’ for either brand never really did magical wonders for the payers, the cardiac network is influential, and I think the companies are now maybe reconciling a ‘payer value story’.

There was a scary moment for one of the companies – a serious hospital discount nearly had us giving away one of the brands as a 12-month supply on the rucksack of a patient discharged from the angio suite – with a cost-saving share with the PCT. The company in question quickly made that disappear! It’s fascinating and like a game of chess sometimes…

Dronedarone. Even with a NICE TAG behind it, this has not been easy to implement. It really does take some serious ‘heads-together’ and I have never seen such fierce debate between clinicians and payers. Affordability and the increasing prevalence of AF makes for a great D&T discussion.

The next meeting I have with the directorate is to implement the use of this agent in young patients – outside NICE who recommended in 75yr+ – as the clinicians see greatest benefit here. This is where the payer’s approach needs serious consideration. All being well, I’ve managed to create an amber/shared care with PCT funding to keep all happy – let’s see what happens at the formalisation and authorisation meeting.

NICE chest pain implementation. There are significant stakeholders here with a number of large meetings across the PCT – payers, consultants, commissioners, coronary care units, etc. The implementation involves a number of small ‘mini-projects’, putting different drugs into the formulary for specific uses to help implement NICE.

That’s the way proper process mapping occurs. It’s more about the drug assisting the pathway, not about the drug per se. I see a lot of work to be done here. But I also expect to see consistency across the PCT.

Read Omar’s previous article in this series on Account Management in pharma.

Omar Ali is the Formulary Development Pharmacist for Surrey & Sussex Healthcare NHS Trust and sits on the External Reference Group for Cost Impact Modelling for NICE. He may be reached on omar.ali@sash.nhs.uk

The Health and Social Care Bill has been passed for the third and final time in the House of Commons yesterday, after a two-day debate.

The Bill, which secured a majority of 65 votes with only four Liberal Democrat MPs voting against it, now goes on the House of Lords.

A major issue of contention was Health Minister Lord Howe’s statement this week that the NHS reforms mean “huge opportunities” for private health providers.

Prime Minister David Cameron’s claim that the Bill now has the support of GPs and nurses was also challenged by relevant professional bodies.

The Government’s ‘listening exercise’ resulted in changes that toned down the Bill’s emphasis on competition between providers – for example, changing the proposed core duty of Monitor from promoting competition to protecting and promoting “the interests of patients”.

However, claims that these changes represented a major policy shift were challenged by Lord Howe’s statement, made this week to a meeting of private health groups in London, that the new legislation would create “huge opportunities” for them.

“I don’t think it should matter one jot whether a patient is looked after by a hospital or a medical professional from the public, private or charitable sector,” he added.

BMA spokesman Dr Laurence Buckman BMA commented: “Lord Howe's comments betray how deep the government's misguided obsession with competition goes.

“Encouraging private providers in, in this way, to compete against other providers will only make it harder for clinicians to work together effectively – and it's that, not competition, which improves patient care and the cost-effectiveness of the NHS.”

In the course of the Commons debate, Health Secretary Andrew Lansley claimed it was “ludicrous scaremongering” to assert that the Health Bill would lead to NHS privatisation, since the NHS would remain a free service.

However, as critics have pointed out, certain aspects of privatisation are indisputably part of the NHS reform programme. The rationing of NHS services – for example, making cataract and orthopaedic surgery available only in the most severe cases – is already a reality, while increasing the role of the private sector in NHS service provision is a firm aspect of Government policy.

The Commons debate revolved around issues that have remained contentious since the first version of the Bill, including provider competition, the role of the National Commissioning Board, and the question of how patient care will be maintained when ‘failing’ Foundation Trusts go out of business.

The chief concern of the Health and Social Care Bill’s critics in the NHS and Parliament remains that it will destabilise the NHS, with provider competition resulting in progressive privatisation.

David Cameron’s claim that the Bill enjoys the support of “the Royal College of GPs, the physicians, the nurses, people working in the health service” prompted criticism from two relevant professional organisations.

• Dr Peter Carter, General Secretary of the Royal College of Nursing, said: “At a time when the NHS needs to find £20bn in efficiencies, tackle waste, work harder to prevent ill-health and deal with an ageing population, this bill risks creating a new and expensive bureaucracy and fragmenting care.”
• Dr Clare Gerada, Chair of the Royal College of GPs, commented: “We are extremely worried that these reforms will lead to an increase in damaging competition, an increase in health inequalities, and to massively increased costs in implementing this new system.”

While it has won a major political battle in its campaign for market-led NHS reforms, the Government still has to gain the support of those clinicians it has repeatedly claimed it wants only to ‘empower’.

The BMA has called for the revised Health and Social Care Bill to be withdrawn or substantially amended, arguing that its plans for competitive and market-led NHS reform still threaten the quality and integrity of services.

In a letter to all MPs, BMA Council Chairman Dr Hamish Meldrum has said that even in its current revised form, the Bill presents an “unacceptably high risk to the NHS, threatening its ability to operate effectively and equitably, now and in the future.”

The third reading of the Health and Social Care Bill in the House of Commons is due to take place on 6 and 7 September, after which the Bill will transfer to the House of Lords.

Dr Meldrum argued that the Bill places “an inappropriate and misguided reliance on ‘market forces’ to shape services”, with the “potential to destabilise local health economies” and, in the long term, to harm public health.

He also noted that, far from overcoming bureaucracy, the Bill is now creating a US-style legalistic environment of “excessive complexity and bureaucracy” to support competition between providers.

The BMA’s main concerns include:

• The Secretary of State is still not responsible for providing a comprehensive health service, only for ‘promoting’ one.
• The removal of the cap on Foundation Trusts’ income from private patients could lead them to focus their resources on private care.
• Forcing all NHS Trusts to become FTs could compromise patient safety and quality of care by placing a premium on financial targets.
• Promoting an increase in choice of providers appears to be a higher priority than tackling health inequalities and promoting integrated care.

“Meaningful, sustainable reform needs to have the full confidence of patients and those working in the health service,” Dr Meldrum concluded – and despite its apparent benefits to their professional interests, GPs remain predominantly opposed to the Government’s plan for the NHS.

Opticians could soon help identify millions of people with previously undiagnosed type II diabetes with a simple finger prick test, a study has recommended.

The study by Durham University found that 32% of 1,000 people were referred to their GP for further investigation after having their blood glucose levels tested at their opticians.

The blood test would be taken during routine eye appointments, to aid early diagnosis of the condition, which is the leading cause of blindness in the working age population.

Dr Jenny Howse, lead study author and former optician, said: “The screening test is less invasive and time consuming than fasting blood glucose and oral glucose tolerance tests.”

The test could ultimately reduce NHS costs and has potential for worldwide use.

The study suggests that diabetes testing in unconventional settings, such as opticians, chiropodists or dentists could detect the condition in those who do not visit their GP on a regular basis.

Dr Howse stated: “There is still a ‘hard-to-reach’ group who remain undiagnosed. Opticians could provide routine, non-emergency care and the simple screening can be done outside usual medical settings.”

It is estimated that 150 million people worldwide have diabetes but up to 50% of this figure are believed to be unaware, sometimes delaying diagnosis until complications occur.

“Already pharmacists and chiropodists have shown it is feasible to offer screening in their practices, here in the UK as well as in Australia and Switzerland. In the US, 60% of adults visit dentists at least once a year for standard check-ups and those practices could be suitable locations to screen for diabetes,” commented Dr Howse.

“We now need to look at the practicalities of delivering it, including liaison between opticians and GPs and the time costs for opticians.”