Labour plans to scrap the Government’s controversial NHS reforms if they win the next general election, Shadow Health Secretary Andy Burnham (pictured) has said.

Speaking in Parliament during a debate opposing the reforms, Mr Burnham insisted the changes open the door to privatisation within the NHS and undermine the health service in general.

He said that Labour will “repeal the bill” if elected claiming it to be a “defective, sub-optimal piece of legislation” that has left the NHS with a “complicated mess”.

The Shadow Health Secretary added that it would be “irresponsible” to leave the Health Act in place if Labour were elected and added that the “gap between ministers’ complacent statements and people’s real experience of the NHS gets wider every week”.

“They are in denial about the effects of their reorganisation in the real world, it is dangerous complacency and it can’t be allowed to continue.”

Health Minister Simon Burns countered Mr Burnham’s claims by reminding the Leigh MP that Labour leader Ed Miliband had previously said he would keep clinical commissioning in place if elected as prime minister.

But the former Health Secretary insisted “it’s not about the organisations, it’s about the services they provide”.

“The existing organisations can be asked to work differently, as I would ask them to work differently,” he said.

“I don’t want those NHS organisations in outright competition, hospital versus hospital. I want them working collaboratively.”

After all the hullaballoo, the controversial Health & Social Care Bill quietly achieved Royal Assent during the afternoon of the final Tuesday in March. One suspects that the difficulties the Government had in getting the legislation passed through will be dwarfed by the challenges the NHS faces in implementing its complex measures. Tuesday 27 March was most likely the calm before the storm.

At present, the NHS is in transition. Within twelve months, 151 Primary Care Trusts will be replaced by circa 250 Clinical Commissioning Groups, spearheaded by a National Commissioning Board. Of course we already know this. But while we wait for the momentous occasion to arrive, how does the pharmaceutical industry approach the critical issue of targeting its key customers?

As Mike Sobanja, Chief Executive of NHS Alliance, notes in this issue, pharma is currently embarking on a new game: “spot the commissioner”. PCTs are currently legally accountable for around 80% of a total NHS budget of roughly £110 billion. Of this, approximately £30 billion has already been delegated to CCGs operating in shadow format. The challenge for medical sales professionals does not end at identifying who holds the purse strings for that £30 billion. The trick, once they have, is to understand their customers’ environments – and their commissioning intentions in their own specific disease areas – in order to have the best chance of securing a slice of the pie.

The next twelve months will provide the strongest test yet for the industry’s recently-acquired penchant for the account management model. Faced with a health service in transition and a ‘confusion of NHS customer-groups’ (Ed. – the most appropriate of collective nouns), the battle ahead will be tough.

Only account managers with the most robust local knowledge will win.

Chris Ross, Editor.

The Government looks set to have won its battle over the Health and Social Care Bill after the last attempt to halt the legislation failed in the House of Commons.

An emergency debate by Labour to block the changes to the Bill until a risk register was published was defeated by 328 votes to 246.

Andy Burnham, Shadow Health Secretary – who pushed for the risk register to be published – said that the general public would “struggle to understand” how MPs had made “such momentous decisions” without considering all of the evidence on the reforms.

Final amendments to the controversial reforms were approved by MPs paving the way for Royal Assent for the Bill before the break for Easter next week.

Peers in the House of Lords approved the Bill on Monday evening.

The changes to the structure of the NHS will see Strategic Health Authorities and Primary Care Trusts abolished in favour of local Clinical Commissioning Groups. The move, which will see GPs given budgetary responsibilities and the opportunity to outsource services privately, has been widely opposed.

Mr Burnham admitted that the legislation becoming law was inevitable and the only hope left to defeat the Government’s plans would be a “change of heart” from the Lib Dems.

“We have given this fight everything that we had,” he said. “All I can say is our fight will go on to protect and restore this party’s finest achievement.”

Rebel Liberal Democrat and Labour MPs have lost two separate votes in the House of Commons in their attempts to amend and completely withdraw the Health and Social Care Bill.

Lib Dem MP Andrew George’s amendment to overhaul the way the NHS is managed was defeated by a majority of 54 votes.

The Government also defeated a similar Labour-led motion calling for the Bill to be scrapped by 314 votes to 258.

After the victories, Health Minister Simon Burns told the BBC he was now “very confident” that the Bill would make it to Royal Assent and become law by the spring.

It now returns to the House of Lords on Monday, before being sent back to the House of Commons.

Health Secretary Andrew Lansley insisted that the reforms to the NHS were the “right idea” and that Labour’s attempts to get the Bill scrapped was a “desperate ploy from a desperate party”.

Meanwhile, the Royal College of General Practitioners has confirmed its opposition to the Health Bill after reports it was willing to work with the Government on its controversial reforms.

A letter from RCGP Chair Dr Clare Gerada to David Cameron said she hoped the Government would work with the College “together to make the health service secure, stable, and safe, now and in the future”.

But in a statement on the College’s website, it said their “position is unchanged and remains consistent – we still call for the withdrawal of the Health and Social Care Bill”.

“We have repeatedly said that this Bill will have a damaging effect on patient care and will fragment the services that the NHS provides,” the statement said. “Whatever the future of the Bill, there is an urgent need to secure the stability of the NHS in England now.

“That is why we wrote to the Prime Minister calling for him to work with GPs to find a stable way forward, and stressing that we need more GPs, with longer training, spending more time with their patients to ensure this future stability.

“This does not in any way change our stance on the Bill – it remains a real high risk to the future of the NHS, and we continue to call on all legislators in Parliament to do all they can to withdraw it.”

Who exactly is pharma’s customer these days? Jessica Henderson takes a look in the NHS customer showroom and urges sales and marketing executives to examine all the features and benefits when choosing the right vehicle for their brand.

The UK Government’s floundering Health and Social Care Bill has been widely decried as “a car crash that has already happened”. But critics predict further pile-ups around the corner as the beleaguered Health Secretary finds himself increasingly stuck in bad traffic on the road to reform. It’s fair to say that the Bill is enduring a difficult journey towards Royal Assent – but irrespective of when, or indeed if, it reaches its final destination, it’s clear that work on the ground to transform the NHS into its new shape and structure has been ongoing since the White Paper in July 2010. There have been delays and roadblocks along the way, but across the country, local NHS organisations have been moving towards the promised land of Clinical Commissioning Groups for well over a year. And as a consequence, the pharmaceutical industry’s customer-base has incrementally shifted – with the prospect of more twists and turns to come. We may not yet be motoring towards reform – but the wheels are well and truly in motion. And it’s driving pharma companies down a familiar road where they are being forced to revisit the age-old question: “just exactly who is my customer?”

The NHS customer showroom
For UK pharma, NHS customers have always been a moving target – but the rate, scale and definition of impending change has meant that the latest movements are proving more difficult to track. In the car (or should that be ‘care’?) showroom that is the NHS, the staff, partners and customers all know that there’s a new model on the way, but they don’t entirely know what it will look like when it arrives, and whether it will work when it gets here. And it may not even leave the factory. But many also believe that the second-hand model that’s been driven around since 1948 is old, creaking and costing a fortune to keep on the road. It was certainly built for a different era where there was far less traffic. And as demand has increased, the size of the problem, as well as the size of the NHS itself, has increased with it. For pharma, the NHS customer showroom has expanded rapidly.

The Toyota Prius: CCGs
The proposed new model is, of course, an NHS that, in England, is led by Clinical Commissioning Groups (CCGs). There are already a few early models in the showroom – in fact, more and more are being test driven right across the country as we speak. CCGs can perhaps be considered as the health service equivalent of the Toyota Prius – a hybrid model comprising of clinicians and commissioners, with similarly green objectives to save their environment and become sustainable vehicles that use their resources effectively.

From BMW to white van? The depreciation of PCTs
For the past decade, the NHS has been run by PCTs, who issued instruction to clinicians in primary care and commissioned and managed local health services. As we know, under the new proposals, the old PCT model is to be discontinued. The inference is that PCTs have, like a saloon BMW with added extras, become expensive to run and, in austere times, are an unnecessary luxury. Instead, commissioning responsibilities will be passed to clinicians – chiefly GPs – who will be handed the car keys and given the authority and autonomy to drive local services as they see fit.

GPs have become accustomed to playing the role of a reliable Ford Focus, simply and efficiently getting the job done and concentrating on the core competency of delivering patient care. But now they are at the crossroads, deciding whether or not to upgrade and move into the fast lane of a more adventurous commissioning role within a CCG, or to stay within their comfort zone of standard general practice. At the same time, many within PCTs face the prospect of the BMW being downgraded to a simple White Van; delivering support to CCGs from the edges as part of Commissioning Support Services (CSSs),  a marketplace that is apparently – and perhaps contentiously – open to huge competition. 

The Porsches
One customer group that appears to have emerged unscathed from the reforms is Medicines Management, perhaps the Porsche within the NHS customer showroom. These will remain important, high-powered and influential customers that preside over high budgets.

What car?
The question for pharmaceutical sales and marketing executives, then, is which customer vehicle is the most appropriate for their individual brands? With the immediate direction of travel for the Health and Social Care Bill still unclear, an already complicated customer matrix becomes ever more difficult. Will the NHS landscape really be governed by a generation of hybrids? Will there be a power struggle between CCGs and CSSs, or will the previously powerful PCTs allow themselves to be reduced to ‘white van delivery vehicles’ without putting up a fight? Or will they simply be rebadged as CSSs and surreptitiously given the same powers as before?

The answers will, of course, vary from region to region – with a clear message emerging from the reforms that a one-size-fits-all solution to health service delivery is simply not feasible in the modern day. Local health economies are being given the autonomy to develop health services to meet the needs of their patient populations, and as such, regional approaches will evolve at varying speeds. But, despite the alleged congestion at ground level, there are already parts of the country where proactive local health organisations are making real progress along the road to reform. Whilst each local health economy will be unique in its approach, lessons can be learned and best practice can be shared – both from an NHS and an industry perspective – by examining progress within the more proactive health organisations, and how they are approaching the change process.

Learner plates for pharma
Working within the Transformation Team has demonstrated how important it will be for pharmaceutical sales and marketing executives to understand their local health economies – not only as CCGs become embedded, but equally as importantly, as they move through the transitional phase. The opportunities for pharma to help local NHS customers to equip themselves for the new model are great – but to maximise them, and in the process give their brands the best chance for success, companies must ensure they are engaging with the right customers. So which ‘vehicles’ should pharma invest in? The answer will vary from region to region and from disease area to disease area. But some general lessons can already be learned:

The CCG Prius
This will undoubtedly seem the most obvious vehicle choice for pharma, given current trends – but at this stage, it may not always prove the most successful approach. In some parts of the country, real GP leadership is already evident, typified by the movement of QIPP programmes to CCGs. But some readily-formed CCGs may in fact be BMWs disguised as a Prius – and less susceptible to working differently. The GP Commissioner in these organisations may not yet be your best customer – and you may need to change gear to accommodate this.

The Ford Focus GPs
The enormity of the challenges ahead has slowly dawned upon even the most proactive GPs. It is now clear to them that the scale of their prospective responsibilities are vast and potentially intimidating. The responsibilities associated with the ownership of costs associated with high referrals and inappropriate prescribing are quickly being realised – but helping jobbing GPs to minimise these costs could present a real opportunity for pharma. Primary care does not need to be a swanky Ford Focus ST, but it can’t afford to be a 10-year old rust bucket either. The more proactive pharma companies may be able to help them learn to drive.

The Porsche Medicines Management
Medicines management is not only here to stay, but it will remain a key customer for the pharmaceutical industry. GPs have recognised that medicines management has assumed huge importance in a cost-driven climate and, as embryonic CCG arrangements develop, many proactive clinicians are considering employing medicines management directly on headcount rather than parking them in the car lot of CSSs.

The white delivery van CSSs
The power of these organisations is likely to be variable across the country. Less engaged CCGs may well devolve a lot of decision-making to CSSs, which could really put them in the driving seat – to the extent that they become rebadged BMWs. At present there has been real conflict of interest between PCT clusters trying to get their CSS models in place without a definitive financial envelope as CCGs consider how to carve up the £25 a head budget alongside trying to negotiate the authorisation process and design the organisation they want. An outcomes-based approach by CCGs to the development of CSSs may make CSSs a real opportunity for industry to tap into. In addition, there are a number of other vehicles that pharma should not rule out:

• The Rolls-Royce – the National Commissioning Board (NCB). Although the NCB’s role is not supposed to be prescriptive, the concept of sharing best practice and buy-in to initiatives with demonstrable outcomes may present pharma with opportunities for partnership.
• The people carriers – Clinical Senates. These will play an advisory role, with disease area specialists providing a clinical check on commissioning plans for CCGs. At present, the geography of clinical senates appears to be largely mirroring PCT clusters, but their final form may depend on how the NCB develops a regional presence.
• The cross-border ferry – Health and Wellbeing Boards. As integrated care becomes a major priority, in disease areas where health and social care overlap, this alternative means of travel may well be worth boarding
• The 4-by-4s – the hospitals. The integrated care agenda has seen the hospital model of care come in for much criticism for being expensive and unsustainable – but the big providers will remain important and will be working towards improved outcomes. They will need all the help they can get.

Moving through the gears
The NHS landscape continues to change and with it, the industry’s key influencers – and the influences they have – are moving too. In a variable and dynamic marketplace, pharmaceutical sales and marketing executives must be agile and flexible enough to adapt to change. Only by taking the time to understand the environment – not only at national level but, more importantly, at local level – will the industry reap the rewards. There is a new roadmap for the NHS and, for individual marketers, the challenge is to ensure your products reach the final destination: being used by your target patient. Success will depend upon making sure you go to the right customers via the quickest route, and this should be achieved through doing what you do best; networking and tracking where your key customers are going.

Selling into the NHS has always been a challenge – it is a complicated customer matrix. The industry’s influencers are different everywhere, dependent upon region, disease area and economics. The most successful marketers will be those that understand local needs and tailor their services that help meet them, delivering relevant outcomes in the process. Whatever the fate of the Health and Social Care Bill, the terms of engagement between pharma and NHS are unlikely to change and the key ingredient for success will continue to be the ability to be customer-centric.

The Government’s NHS reforms may yet prove to be the car crash that has already happened, but don’t allow your sales and marketing approach to become exposed to the same accusation. The industry can help all of its NHS customers drive improvements to patient care – it’s all about finding the right vehicle. Now belt up!

Snapshot review of an emerging CCG

In October 2010, I was seconded into the NHS to provide additional resource to a Transformation Team charged with managing the transition of a PCT into the new CCG model. The project covered a large geography and involved three established PBC teams, each with different responsibilities, structures and cultures. The Transformation Team was multi-disciplinary, but included clinicians who were strong advocates of clinical commissioning. The group would eventually emerge as one of the first wave Pathfinders.

The transition project required the team to evaluate every function of the existing PCT, and to establish which of these should form part of the CCG function and which could be outsourced. The scale of functionality of a standard PCT is broad and vast. It includes aspects such as medicines management, information/data management technology, decision support systems, HR support, contracts/procurement, legal finance and communications.

The challenges and considerations were huge; which services are critical to running a commissioning organisation with a budget of around £700 million, and therefore should remain in-house? Which could be outsourced to CSSs, who may be able to provide them more cost-effectively? Should the CSS be brought in-house, to ensure control over key aspects such as IT and other back-office functions? Should medicines management be included on headcount?

The CCGs established a Clinical Commissioning Board, comprising a multidisciplinary panel of CCG and PCT representatives, to drive decision-making and ensure it was clinically-led. The CCGs were divided into seven localities, each with a Locality Lead that had previously sat within the PBC groups. As part of the transformation process, the GPs who have declared an interested in assuming commissioning responsibilities are being taken through a training programme to upskill them for the future model. This process is ongoing. The scale of the challenge for GPs is recognised to be huge.

The Board created a blueprint for  Commissioning Support Services and agreed the outcomes that they wanted to achieve from it, its functions and objectives. This was done in collaboration with over 100 GPs, who worked through a long clinical commissioning transformation process to jointly agree how existing PCT functions would be transformed and where they should sit within the CCG.

The NHS is currently firefighting with uncertainty, but alongside all this transformation work there is still the undercurrent of ‘business as usual’ to ensure the wheels are kept on the organisation. Commissioners are continuing to carry out their day jobs amongst all this uncertainty, and need support to make their mark in what will be a competitive jobs market as commissioning roles reduce to accommodate the £25 a head budget which has been granted to CCGs.

Jessica Henderson is a Research Associate at WG Consulting Healthcare Ltd.

More than 2,000 uniformed healthcare professionals and patients have filled Central Hall Westminster in opposition against the Government’s controversial Health and Social Care Bill.

The All Together for the NHS campaign, organised by the TUC, saw an alliance of union members and high-profile individuals from royal colleges and professional groups rally against the reforms.

Brendan Barber, TUC General Secretary, said in a speech at the rally it was “vital that we make our voice heard” and the Health Bill was the “biggest threat our NHS has ever seen”.

In one of more than 30 speeches, Mr Barber said the campaign aimed to maintain a “publicly-accountable health service, for the values that make our NHS special, and for the ethos of public service itself.”

“I want the message to go out loud and clear that our NHS is not for sale, not today, not tomorrow, and not ever,” he said.

“The Bill will also mean privatisation on a huge scale, with our health service opened up to competition by any willing provider. Private firms will profit by cherry-picking the easiest, most lucrative work – leaving the taxpayer to pick up the tab for everything else. That is simply not acceptable.”

He added that the reforms were “wrong for patients, wrong for the public, and wrong for Britain”.

The Prime Minister, Mr Barber said, also needs to understand that he will pay a “devastating political price” if he presses ahead with the “ill-conceived, reckless, expensive Bill”.

“We will not allow this government to destroy what has taken generations to build,” he insisted.

Other speakers at the rally included the comedian Jo Brand, who used to work as a psychiatric nurse, Shadow health secretary Andy Burnham MP, crossbench Peer Lord Owen, Liberal Democrat MP Andrew George, UNISON General Secretary Dave Prentis and BMA Chairman Dr Hamish Meldrum.

Dave Prentis commented that patients will face growing waiting lists if the controversial legislation continues its passage to Royal Assent. “Introducing competition into the NHS will usher in private companies,” he said. “They will put profit before patients. Where you have competition you have winners and losers and it will mean that patients are hit as some hospitals close. Taking the cap off the number of private patients that can be treated by a hospital means that those who can pay will go to the front of the queue.”

The Government has again made amendments to its Health and Social Care Bill as it attempts to address Liberal Democrat concerns.

Further safeguards have been added over private patient income and to clarify and extend the compliance powers of Monitor over foundation trusts.

Health Minister Earl Howe hopes the amendments will provide “ongoing reassurance that the NHS will always operate in the interests of patients”.

However, the series of amendments which have been added to the Bill during its passage through Lords are still not enough for certain Liberal Democrats. Activists are aiming to hold a vote to axe the reforms at the party’s spring conference later this week.

The amendments to the powers of Monitor will now see it able to direct foundation trusts to change their boards when there are concerns it “will fail to comply with the conditions of its licence”, said Earl Howe.

Although it will not maintain its existing compliance regime over trusts, it will mean the regulator continues its extensive powers over foundation trusts until the health secretary makes a parliamentary order.

Changes have also been made on the issue of trusts benefiting from income from private patients. The amendments will now mean trusts will have to declare annual plans to increase non-NHS income. If these plans aim to increase income by five percentage points of overall income, the Department of Health would then have to agree to the proposals.

“The principles of our modernisation plans – doctors and nurses making decisions, patients being at the heart of the health system, and less bureaucracy – have always been at the core of the Bill,” said Earl Howe.

“These principles are widely accepted according to the independent NHS Future Forum. We will continue to work with peers to provide the reassurance and clarity necessary as the Health Bill progresses through Parliament.”

The controversial Health Bill returns to the Lords this afternoon.

The chair of Tower Hamlets Clinical Commissioning Group, Sam Everington, has written to David Cameron calling for him to withdraw the controversial Health and Social Care Bill.

Mr Everington claims that local commissioning decisions already take place within his area and “an act of Parliament is not needed to make this happen” throughout the country.

In the letter posted on the internet, he said his CCG shares the concerns of the Royal College of General Practitioners and the British Medical Association in opposing the Bill.

“The Board of NHS Tower Hamlets Clinical Commissioning Group ask you to reflect and to withdraw the Health and Social Care Bill,” he said.

“Supporting improvements in the quality of patient care is our passion and focus. We support a strong role for clinical involvement in commissioning decisions that lead to better health outcomes for our patients. We do this already in Tower Hamlets.

“Tower Hamlets primary care team has a long tradition and reputation for innovation and commitment to partnership working with patients and managers. We make the best of any challenges that come our way. Innovations include real improvements in the health of our patients with chronic illnesses like diabetes, the highest childhood vaccination rates in London, and an exemplary local out of hours service, delivered by our GPs and highly valued by patients.”

Mr Everington added that his CCG already works in partnership with the local community and health services “to improve and integrate services for the benefit of our patients”. The GP said that it was “against this background that we represent the views of our local GPs in asking you to withdraw the Bill”.

“Clinicians, patients and managers in Tower Hamlets are determined to improve health and well-being, but your rolling restructuring of the NHS compromises our ability to focus on what really counts – improving quality of services for patients, and ensuring value for money during a period of financial restraint,” he said.

“We care deeply about the patients that we see every day and we believe the improvements we all want to see in the NHS can be achieved without the bureaucracy generated by the Bill.”

Pf Editor, Chris Ross, asks who pharma’s customers really are as the NHS reforms continue to progress.

The journey towards NHS reform was always likely to be a long and painful one for the coalition government – but, as opposition to the Health & Social Care Bill grows stronger by the day, it’s becoming increasingly difficult to predict where the journey will end. At present, Royal Assent seems many miles away.

But despite the fierce political and ideological objections to the proposals, in many parts of the country the NHS has already ventured some way along the roadmap to reorganisation. Embryonic Clinical Commissioning Groups are steadily establishing themselves across England, and the transfer of powers from PCTs to the new commissioning organisations is well underway. It is likely to prove costly for NHS productivity and patient care if the journey to reform finds itself at a dead end and the Kill the Bill movement finally succeeds.

Whatever happens in the coming weeks and months, the ramifications for the pharmaceutical industry have already been significant. Since the introduction of PCOs, PCGs, PCTs and, of course, NICE in the early 2000s, UK pharma companies have spent the best part of a decade trying to establish exactly who their customers are and realigning their sales and marketing efforts accordingly. During that time, it’s become increasingly clear that a one-size-fits-all solution to customer segmentation will not work, and that the identity of so-called ‘key accounts’ will vary from region to region, and disease area to disease area. In such a dynamic and fast-moving environment, the work of field-based medical sales professionals becomes ever more important. The role of the rep may have been redefined in the past ten years, but while numbers on the ground have dropped significantly, their value to UK pharma in a changing marketplace has only increased.

Chris Ross, Editor.

The Government’s controversial NHS reforms have again come under increasing attack as Lib Dem peers in the House of Lords are set to launch fresh amendments to the Health and Social Care Bill.

Lib Dem peers have again tabled a series of amendments including plans that allow the Competition Commission powers to review competition and that Foundation Trusts require permission from governors before sanctioning private contracts.

Tim Farron, President of the Lib Dems, has also called for all elements of competition to be scrapped from the legislation – which is set to resume its passage in Lords this week.

The Lib Dem move follows calls from Labour leader Ed Miliband to join forces with his party’s peers to put a halt to the reforms.

Writing in a letter in the Sunday Mirror, Mr Miliband said it was now time to make a stand before it’s too late. “The Liberal Democrats in the House of Lords must join with Labour to hole David Cameron’s health plans below the water line,” he said.

“If they do not the betrayal by the Lib Dems in allowing this bill through will be bigger than the row over university tuition fees.

“They will betray not only the people who rely on today’s NHS, but also generations to come.”

Mr Miliband’s comments followed those of former NHS Chief Executive Lord Crisp who described the reforms as a “mess” and missing the point.

Lord Crisp, speaking to the BBC Radio 4’s The World This Weekend, said he believed the bill was “unfortunately setting the NHS back”.

“I think the great mistake that the current Government has made – and I can say this as an independent and not a politician – is that this is a terrible confused and confusing bill,” he said.

“It has tried to elevate the ideas of competition and the use of the private sector, which are just mechanics, just mechanisms, as if they were the purpose.”

A DH spokesman played down the on-going criticisms of the reforms insisting the plans will

“harness the expertise of local doctors and nurses, who know better than anyone what their patients need”.

“The proposals promote health in partnership between the NHS and local communities and put local authorities in the driving seat alongside clinicians for improving the health of their communities,” said the spokesman.

“Improving integration between all health and care services is a crucial part of modernising the NHS.”