This month Brigadier Pinching shares a surprisingly palatable civil service coffee with the Department of Health’s NHS/big pharma relationship expert, Naima Khondkar.

I love Elephant and Castle. If you are in any doubt about where you are, just outside the station, there is large sculpture of... an elephant and a castle. Oxford Circus, King’s Cross and Cockfosters have clearly missed out on a neat trick. Anyway, I digress, for I was in central London on important business – to chat with Naima about how the private and public sector could make their marriage work. Having spent six years in curious governmental buildings, this was my territory. Bring on the future!

Hi Naima, what’s your story?

At the Department of Health I work in the Medicines, Pharmacy and Industry Group. The head is Giles Denham and he has a number of teams which sit under him. One looks after the pricing environment – which is very topical right now because of the negotiations – while the pharmacy team takes care of community and pharmacy issues. Another concentrates on prescription policy, and I’m in the industry sponsorship team.

How do you guys roll?

We’re almost account managers for the pharmaceutical industry, within government, and also the first port of call on health policy issues concerning research-based pharma companies, including global outfits that have locations in the UK. There’s a very high-level of strategic engagement, driven by the Ministerial Industry Strategy Group, which combines global heads of pharma, from as far afield as Japan and America, and ministers from health, business, the treasury and UKTI (UK Trade and Investment). The discussions are a great way to highlight how government policy can help partnerships. Our minister, Earl Howe, is a particularly engaging contributor, while ‘No 10’ frequently sends along a representative, indicating how serious the Government is about forming cohesive inter-sector partnerships.

How has the concept of joint working progressed?

Over the last few years we have carefully considered how to fundamentally improve the relationship between industry and the NHS, and a lot of this consideration has been carried out in conjunction with colleagues at the ABPI. There is still a lot of mistrust on both sides, however, and that is one of the greatest challenges reform needs to overcome. The NHS has the perception of pharma as being a big bad wolf, just above the arms and tobacco industries in terms of popularity! For some reason people have a big problem with the pharmaceutical industry making any kind of money. Sometimes I think the level of suspicion is unjustified, but then again, I don’t think pharma do themselves many favours sometimes. It’s important to be open and honest about these things! Equally, the NHS can sometimes be over-sensitive – they don’t like to be told by other people how to do their job.

What needs to change?

There needs to be a shift in how people on both sides view one another and they must learn to wipe the slate clean. Bad relationships can date back to minor incidents that happened 25 years ago, when a young, naive rep went into a meeting with a box of doughnuts to help flog a new product. Something as trivial as this may have resulted in a door being shut. Whereas now NHS representatives need to re-engage, open doors and think about the broader benefits of working together with the pharmaceutical industry towards joint goals. It’s really important that both sides build allegiances and forget past animosities. Ultimately this will benefit everyone.

Do the ‘different’ motivations of the public and private sector make gelling difficult?

There is an incorrect perception that, because pharma makes money, someone else has lost. We must remember that if people have their lives extended due to better treatment then NHS, industry and wider society has won. Recently Helen Bevan, NHS Director for Transformation, said both industries have been very target driven in the last 15 years and, consequently, the humanity factor has eroded. Healthcare professionals on the frontline have been too busy with waiting lists and reductions, while sales reps have been under enormous pressure to shift products and been too focussed on sales. Patient cases have become about performance measurement rather than health outcome, or quality of experience. Clearly there needs to be a radical change in priorities.

What can big pharma do to engender trust?

Their approach can be ill-informed sometimes. Often they think they know the NHS, but actually they need to fully appreciate the complexities of what is an ever-evolving beast. Companies need to consider who they make responsible to forge vital connections and forming sustainable relationships. They regularly send an under-qualified person, who might have the enthusiasm, but not the authority. With joint working one of the big issues has been compliance and, often, the pharma representative at the table can’t actually make a decision about whether a company can work in a certain way. This is one of the areas we are really trying to help with.

How should they alter their approach?

If pharma goes in simply looking for a market share increase, they’ll get figured out straight away. Representatives of the big companies need to prove that they genuinely want to improve a health economy or health outcome, before profits. These are the aspects that make the whole system better, and ultimately everyone wins. The CCGs want more people appropriately treated and that means less hospital admissions and, in turn, more financial resources will be available for commissioning. In this respect pharma needs to look at the bigger picture. Remember, every service that the NHS uses is a business – from nurses to bed sheets – but because of the fractious history, the NHS is suspicious about pharma making money. When they do engage the NHS needs to feel like pharma is an integrated and credible part of the solution, as opposed to a procured service. It’s a fine balancing act.

What are the priorities when it comes to galvanising joint working?

Since joint working was outlined as part of NHS reform we have been keen to establish how it can be improved. A policy working group in 2007 carried out some market research and they came up with some recommendations. The two major areas of focus, on our side, were the issuing of guidance – clear definitions of how the NHS works - and the language that should be used. This is a refreshingly concise 11 page document. We also addressed the practical side by combining with the ABPI to launch the, ‘Joint Working tool kit’. It’s an interactive quick-start guide, which includes exactly what the NHS’s definition of joint working is, essential templates and a versatile project management tool. Above all, it avoids jargon and allows people to understand what is required straight away. This has been endorsed by NICE, the NHS Alliance and Confederation among others. We will be looking again at how we can update these documents and make them more practical in the ‘new world’ and also partnering with industry [through the ABPI] and the NHS to review and revitalise both these tools.

Are you optimistic about fruitful partnerships?

Joint working will continue to be an important focus and a part of my day job. QiPP came and went, so we had to hold fire for a while, but now Innovation Health and Wealth (IHW) has provided a restructure, we are pretty sure of what is happening; six months ago we sat down and established that the shift of power is moving to CCGs. Now individual CCGs. Director of Partnerships, Ivan Ellul is particularly keen on localised, dynamic relationships and Mike Farrar is also a champion. Ian Carruthers is the NHS England lead for IHW and is also keen to encourage this type of engagement.

Do you feel that the tide is turning already?

I’m resolutely positive about changes within the NHS. I’ve had heated discussions with clinicians and pharma about joint working, because a lot of them see it as more rhetoric. Some companies, however, are hugely proactive and want to be pioneers of change. GSK are a good example. They’ve shifted their entire salesforce to encourage new ways of working with NHS counterparts. Their leader, Andrew Witty, is passionate about successfully transforming approaches and he’s someone you can believe in, because GSK have freed up patents, conformed to the ‘alltrials’ ideology and shared data. This has filtered down to the way they engage with the NHS and the company have been very smart, as they realise it’s about increasing the whole market. If a healthcare pathway improves it will produce better diagnosis, and better diagnosis means more appropriate and timely use of medicines.

Well said, thanks Naima!

A health expert has predicted that the failings of CCGs will see them replaced after only two years by a more effective system of commissioning healthcare services.

Kieran Walshe, Professor of Health Policy Management at Manchester Business School, told the BBC 4’s Today programme that there are no real benefits to GP-led commissioning and accused the Government of being obsessed with this approach.

“This is the most recent version of GP-led commissioning,” he said. “None of them have worked very well. The research suggests there aren’t really great benefits in GP-led commissioning, so why this Government is embarking upon essentially doing the same thing is very hard to follow.”

Professor Walshe said the UK should follow the commissioning models adopted across Europe to get better value for money. He claimed that larger organisations instead of smaller commissioning groups are in a better position to leverage better deals for patients.

“GP commissioning groups are smaller than the old PCTs and are going to be like ‘corner shop commissioners’ – who gets better value for money? A corner shop or a supermarket?” he said.

“The change in all of this which is really interesting is the creation of the NHS Commissioning Board and its local area teams. That’s commissioning at scale. They’re going to be dealing with around 40% of the budget and they will be the driving force in this. In two years’ time I suspect we’ll be back sitting around a table saying ‘CCGs haven’t worked. What shall we put in their place?’ But the scale of commissioning by the NHS Commissioning Board may have some future.”

Dr Michael Dixon, NHS Alliance Chair and acting president NHS Clinical Commissioners, argued that Professor Walsh’s prediction was inaccurate and GP-led commissioning will see improved standards of care. “The benefits [of CCGs] are that doctors and nurses that actually see patients make the decisions as to what needs to happen,” he said.

“The Nuffield Trust report showed only last week that money continues to go into hospitals and not into primary care services. What we need to do is to turn that around.”

CCG leaders must become “demolition experts”, dismantling old services and commissioning new ones, the Chairman of the NHS Alliance has said.

At the pro-reform primary care organisation’s annual conference, Michael Dixon said the new NHS commissioners would achieve a definitive shift in healthcare towards community-based services.

Health secretary Jeremy Hunt also told the NHS Alliance that CCG leaders would achieve the “Holy Grail” of NHS care: the local integration of services.

In his keynote speech, Dixon said the new commissioners’ first task was “to enable redesign that has so persistently failed to materialise under the old order”, building new treatment and care structures in the community.

However, he noted, in the face of economic restrictions, service redesign alone would not be adequate; commissioners would need to “think ever bigger, wider, and more ambitious” in building partnerships with new providers.

The NHS Commissioning Board would need to act as the “grand protector” of CCGs against the “managerial hierarchy” of the old NHS, he argued.

Similarly, Hunt congratulated the new CCG leaders on having “won the argument for having an NHS which is driven by local decision-making and clinical leadership”.

As a result of that victory – which was, in fact, opposed by most clinicians – doctors would “see at a local level the integration of services that has been the Holy Grail for so many people”.

Hunt also praised the previous Government’s aim of creating a “single digital record” for all NHS patients, and said that such a system remained necessary – a notable shift in DH policy.

He promised that online appointments and repeat prescriptions would become standard, but said the viability of e-mail consultations was uncertain.

Finally, admitting that his role may have “a short shelf life”, Hunt reiterated his major goals for the NHS: improving dementia care, reducing mortality from major diseases, implementing new technology, and improving care as well as treatment.

NHS engagement is about combining thorough market intelligence with a robust targeting plan.

The imminent authorisation of the first wave of Clinical Commissioning Groups (CCGs) promises to provide Key Account Managers with yet more information on which they can base their call strategies. By November, 35 CCGs will hope to have successfully navigated the comprehensive authorisation process and be approved to take on their new commissioning duties from April 2013. A further 177 prospective CCGs will be reviewed across the final three authorisation waves, with decisions on all the new local organisations expected by the end of January 2013. The dawn of a new era for commissioning is almost upon us. And as the reform rhetoric turns into reality, a new customer landscape for UK pharma will have emerged.

The four-wave authorisation process will place into the public domain a wide range of important documentation that was required not only to support individual CCG applications but, more importantly, to provide strategic blueprints for the long-term development of these embryonic local health organisations. Key documents include Joint Strategic Needs Assessments, Commissioning Intentions, Integrated Plans, Joint Health & Wellbeing Strategies, Organisational Structure Plans and draft Joint Commissioning Agreements. In some of the more proactive local organisations, such information is already available.

Elsewhere, it remains in late-stage development. Either way, the data and plans set out in these documents will undoubtedly provide crucial insights for KAMs targeting existing, new and emerging decision-makers and influencers at the local level.

And therein lies the problem. Identifying the most important and influential stakeholders in a changing NHS remains one of UK pharma’s biggest challenges. Earlier this year, the NHS Alliance’s Chief Officer, Mike Sobanja, said that the industry was about to embark on a game of ‘Spot the Commissioner’. He was not wrong. But to win, medical sales professionals tasked with the responsibility for identifying and developing key customer accounts must take the gaming metaphor a stage further and set about playing a conventional game of ‘Guess Who?’ Unfortunately, winning won’t be child’s play – it will require an insightful and educated approach.

But guess who, indeed. The current reorganisation of the NHS is bringing an increasing number of players to the table. Alongside CCGs, the Department of Health has recently published further details on the establishment of 27 Local Area Teams (LATs). Ten of these will be specialist commissioning hubs; the remainder will be afforded a variety of commissioning responsibilities. In addition, commissioning will be supported by 12 Clinical Senates, whose full remit is, as yet, unclear. Beyond this, the NHS Commissioning Board (NHS CB) – which itself will exert major influence over local commissioning plans – has more recently rebranded commissioning support services as Commissioning Support Units (CSUs). The NHS CB is currently conducting an authorisation process that will determine which organisations will provide ‘scale services’ to support CCGs – and has approved 23 to date. Critics claim the new CSUs look suspiciously like PCTs.

Regardless, it’s clear that in the very near future, pharma will find some of its key customers are housed in a CSU. They will also reside in fledgling Health & Wellbeing Boards. Undoubtedly, the new commissioning landscape will present a complex customer matrix for the industry.

Such is the speed and scale of the reforms that targeting customers in an environment that appears to be changing on a daily basis could easily be reduced to a guessing game. But pharma’s approach needs to be much more sophisticated than that. KAMs know that the old-school ‘noise-based’ approach to customer engagement will no longer work. Call plans must be targeted and efficient. But how?

Guess who?
The challenge really is like playing a giant NHS-themed game of Guess Who? Figuratively, every KAM has their own game board. The characters on it will differ, in terms of remit and influence, from one local health economy to another. And they will also be dependent upon disease area. A fully comprehensive board will comprise a mixture of clinicians and payers, as well as, potentially, influencers from social care and local authorities. Crucially, the game is as much about ruling out irrelevant customers as it is about identifying key targets. The former will determine the latter. The most adept sales professionals will be those who command sufficient market knowledge to be able to discern between an important stakeholder and a non-starter. They will then be able to use this information to form an efficient call strategy. Market data will clearly inform these targeting decisions. And there is a lot of it out there.

The imminent arrival of strategic documentation emanating from the CCG authorisation process will be just the latest in a deep mine of useful NHS data available to the industry. From QOF data to QIPP plans, HES data to CQUIN frameworks, the modern NHS is generating performance data, indicators and metrics at a rapid rate of knots. Used properly, it can be gold dust.

Local health organisations are being measured on their ability to eliminate variation in care, reduce hospital admissions and improve health outcomes. And they are increasingly required to report on how they are faring against these objectives. Proactive KAMs can use this data to develop messages that target commissioners of care and demonstrate how their drugs can impact service delivery in line with known priorities.

But data is only part of the answer. On its own, information is not enough. Success will only come from having an understanding of what it means, and establishing how it can be targeted in the right direction. A KAM can have all the data in the world, but if they are not able to translate it into an offering that demonstrates a meaningful gain for a customer, it is worthless.

The key account management game of Guess Who? will ultimately be led by the messaging you have developed, which, in turn, will have been driven by local circumstances and those customer needs identified within relevant market data. If you have a health economic message, certain clinical customers can be ruled out. If your value proposition can make a difference to a QOF target, once again, it will dictate a more precise customer group and eliminate others.

The rapidly expanding availability of NHS information promises great national and local insights for KAMs – and the Department of Health’s recently published Information Strategy indicates that a growing emphasis is being placed on the need to capitalise on the promise of data to drive improvements in patient care. But medical sales professionals must not lose sight of the fact that once they have reviewed all the available data and determined their product messaging, they still need to identify the key customers with whom those messages will most resonate. And they must then tackle the industry’s other long-standing challenge: gaining access to them. Having something to offer that can help customers meet their own objectives provides the best possible chance to achieve this.

So it’s clear that, faced with an evolving NHS bedeviled by rising demand, reduced resources and major reorganisation, productive industry engagement will only come through the development of a market access strategy that marries environmental intelligence with accurate customer targeting. This all links back to the need to establish a robust CRM strategy that integrates all aspects of customer data into a single platform, and communicates them effectively and efficiently across the commercial organisation. This approach will prevent KAMs going off in different directions and developing flawed strategies based on poorly-interpreted information.

In a dynamic, fast-changing market, only meaningful engagement that communicates the right message to the right customers will make any discernible difference. Anything else will be pure guesswork.

David Round is General Manager, UK at Cegedim Relationship Management.

The NHS Alliance has warned the Government and the NHS Commissioning Board to allow clinical commissioning to unfold organically.

Dr Michael Dixon, Chair of the Alliance, said GPs must be allowed to make their own commissioning decisions if the NHS reforms are to be a success.

Speaking at a health forum, Dr Dixon said politicians should learn from previous mistakes if clinical commissioning is to be a success.

He commented: “For me, the way the DH and the Commissioning Board are setting things up, seems a bit like saying to David Cameron and Clegg that yes you can come to Government but Gordon Brown will come in and tell you the rules, and then he is going to continually assess you on what you’re doing and come in and take over Government.

“Do you ever create a revolutionary change in that way?”

The NHS Alliance chair also called for GPs to become further engaged in CCGs or they risk being “subservient” in the new NHS.

Dr Dixon also called for the Government to make the commissioning structure as uncomplicated as possible “because if the frontline conditions return to how they were before then we have lost the plot”.

Commissioning Support Services have been rebranded. But what will incoming CSUs actually do?

The infrastructure of commissioning support has evolved rapidly this summer. In the past month, the NHS Commissioning Board Authority has renamed Commissioning Support Services (CSSs) as Commissioning Support Units (CSUs), and introduced 23 CSUs that will be managed by the NHSCB during the transition period. The rebranding is designed to distinguish the NHS units from the wider commissioning support services marketplace. 

The move marks the first part of wider efforts to develop a sustainable network of CSUs. This will be led by a CSU Transition Programme team that will focus on establishing key components of commissioning support, including a standard contract, a CCG procurement framework, market development and the commercial development of CSUs. The Transition Programme Team will be appointed shortly. In the meantime, details of how CSUs will collaborate to provide essential services at scale have been unveiled, following an NHSCBA business review.

CSUs will provide at least one of four ‘scale services’ for CCGs. These are:

• Business intelligence

Business intelligence services will comprise data management and integration centres that provide data validation, integration and storage to cleanse and link national and local data sets. This will ensure that meaningful data are available for further analysis by CCGs and CSUs.

• Healthcare (clinical) procurement

These comprise market management activities such as market engagement, analysis and development. It also includes procurement strategies such as procurement project management, strategy development and process compliance.

• Business support

This includes HR, payroll, procurement of goods and services, legal services, information management and technology.

• Communications and engagement service

The configuration of this area is yet to be finalised.

At present, a number of CSUs are evaluating their capabilities and determining which scale services they wish to provide. However, 23 have been assessed and approved.

Dr Joe Rafferty (pictured), Director of Commissioning Support at the NHSCBA, said the national configurations go a “long way” towards providing stability for CCGs when they take over the responsibilities of PCTs next April.

Context and progress
The NHS reforms opened up a free market to service providers. Officially, any organisation can assist CCGs in tendering for services. But the introduction of support organisations by the NHSCBA provides a safety blanket for CCGs when in need of external commissioning assistance. Although CSUs have been given titles referring to different regions they are free to provide services to any of the 212 CCGs in England. 

CSUs are currently completing the third ‘checkpoint’ stage introduced by the NHSCBA to ensure not only that they are competent and financially robust, but that any “potential commissioning and financial risks are manageable” when they are fully authorised. The Board has made it clear that although it will oversee the transitional stage of these organisations, staff will not be employed by the NHS – nor will it be responsible for the services they tender. CSUs are transitional partners in a shift away from the old healthcare system dictated by top-down management. Also, CCGs have been informed that they will be responsible for the services organised by CSUs.

After the CSUs passed the Board’s first checkpoint at the turn of the year – a peer review process which assessed the preparedness of CSSs to be “responsive” to CCGs’ needs – three CSUs were disbanded during the second stage of the authorisation process. Plans for West Mercia, Peninsula and NHS Communications and Engagement Service CSUs were scrapped after the three were found to have “failed outright in their development”. A further nine CSUs were identified by the NHSCBA as being in need of  “rigorous management” – though the Board agreed to develop them further through its own business development unit. 

The third and final checkpoint will “comprehensively test the full business plan, strategy and overall feasibility” of commissioning services. The deadline for this has been set at the end of September 2012.

Services
Long before the introduction of CCGs and the controversial NHS reforms as part of the Health and Social Care Act, staff working within PCTs were tasked with commissioning services to meet local health needs. It’s expected that the majority of these staff will continue to play prominent roles in future CSUs – allowing pharma to maintain important contacts within the health service. In fact, the first 16 managing directors of the 23 CSUs have now been appointed by the Board and include a number from high profile PCT positions.
The NHSCBA has called upon the units to be “innovative” and provide “greater value for money”. It is expected that the main functions of support organisations will be to assist in transformational and transactional commissioning functions such as procurement, contract negotiation and monitoring and risk stratification.

The NHSCB’s Developing commissioning support: Towards service excellence outlines how CCGs may wish to utilise the services provided by CSUs:

• ‘One stop’ commissioning – CCGs share the services of support units to form a collective power when negotiating with healthcare providers. These services are expected to be built on medium to long-term arrangements.
• Specific products and/or services – although currently delivered by a range of suppliers, CCGs may ask CSUs to deliver assistance through a wider end-to-end commissioning support service.
• Business support – services such as key decision-making activities must be carried out by CCGs but highly transactional functions are likely to be outsourced.
• Scale services support – services that should be delivered for larger populations by a large number of organisations.

The response
A recent report by the National Association of Primary Care and the NHS Alliance found that half of the 212 CCGs across the country expect to source services from CSUs. Slightly less than a third (32%) indicated they plan to use their own in-house expertise with just 5% saying they plan to use services outside the NHS to commission.

CCGs also indicated they plan to work with their local CSUs – and maintain a working relationship with the commissioning support service used as part of their authorisation process. Although concerns were raised over the cost of outsourcing commissioning, nearly half (45%) of CCGs said the costs associated with CSUs were affordable. Only 12% disagreed.

But not all commissioners are sold on the idea of outsourcing services. Only 8% of respondents said that commissioning units can deliver support in a more innovative way than had previously been experienced. Also, the majority of CCGs called for further information on procuring commissioning support and information on choices available to them.

There has also been criticism from CCGs about the number of CSUs across the country and the speed of their development. As part of their own authorisation, commissioning groups must establish a contract with a support organisation. But Dr Joe McGilligan, Chair of ESyDoc CCG, recently revealed that the “most difficult” challenge his organisation faces is finding a CSU. He added that when an offer was received by his local CSU it far exceeded their budget.

Those claims were echoed by the NHS Alliance. Its chair Dr Michael Dixon said there needed to be more than 23 CSUs across the country to serve the 212 CCGs. He said a bottleneck was being created as commissioning groups moved through their own ‘waves’ of authorisation and that a “lack of sellers” may push some commissioners towards the private sector.

The NHSCB recently staged a commissioning support unit scenario to explore the proposed relationship between CCGs and CSUs, and to try and anticipate likely challenges which may be faced in the future. However, if the Board continues to slow down the authorisation of CCGs, it’s expected that many will be forced to turn to the private sector instead of their preferred support unit options. 

NHS Alliance focuses on CCGs’ best practice

The NHS Alliance has published a best practice guide focusing on the success of 12 different CCGs across England.

The guide – Clinical Commissioning in Action – outlines how commissioning projects have helped increase standards of patient care whilst meeting financial targets.

The document outlines how CCGs hold the “key to the future of the NHS” and many clinical commissioners are “already demonstrating their potential to make a real difference”.

“Where real progress has happened, it was only possible through meaningful partnerships combined with willingness and determination from those involved in bringing about change,” the guide says.

“These clinical commissioners have tackled issues head on, drawing on experience of front line staff, their knowledge of the local community and working with local managers.

“Was it easy? Mostly not. Was it worth it? Absolutely. Patients were placed at the heart of the health care system and services were designed to meet their needs.”

The guide states how doctors have often known how to tackle local health issues but have “lacked the mechanisms” to bring about change. But CCGs have given GPs “that leverage” and the opportunity to improve local services has been “seized with both hands”.

Unplanned admissions
NHS Newcastle West and Newcastle North and East CCGs aimed to reduce hospital admissions by providing staff at care homes across the city training, support and input from local GPs.

The scheme was initiated after a hospital doctor found care home residents were admitted as emergencies at an average cost of £8,225 per day. A third of patients were discharged the same day and half within two days. But nearly a fifth (18%) died – many within five days of admission.

To tackle this, the CCGs allocated a link GP who would make regular visits to care homes and build relationships. Staff were also given training on topics such as wound management, falls and also care planning to support individuals who wished to die in their own homes.

The new measures resulted in a 9% reduction in unplanned admissions from care homes, same day discharges being reduced by a quarter and 27% fewer patients dying within a day of being admitted to hospital.

The cost of the project - £250,000 in the first year – was funded by practice-based commissioning savings with ongoing costs expected to be lower as the scheme continues. But savings are “at least as substantial”, the guide said.

David Thorne, Chief Operating Officer, Newcastle West CCG, said the engagement of the GPs had been “vital” to develop the scheme. “GPs instinctively ‘get it’,” he said. “I have not met a GP yet who doesn’t say that this is really important work.”

Bridging the gulf
Collaborative working between NHS South Devon and Torbay CCG and secondary care clinicians aimed to provide safe follow up care to men who have raised prostate specific antigen levels which need monitoring. 

The CCG was keen to avoid visits to outpatient clinics and a worrying six month wait for results for often elderly patients. It has now adopted a model first pioneered in Bath enabling patients to have blood tests locally, who are then contacted with their results. Visits to hospitals are only required if tests are outside the expected range or if patients are concerned about their symptoms.

It is estimated that the new model may save up to 1,500 outpatient appointments annually and generate “substantial potential financial savings,” the guide says.

The scheme was designed by secondary care doctors and GPs working in partnership in a clinical pathway group for urology. Firstly, a consultant decides if a patient is suitable for monitoring. If so, the details are entered into a PSA computer system. Using this information, a urology nurse ensures patients are contacted when they need a check up – which is conducted at a GP surgery. The nurse then contacts the patient again to tell them whether additional tests are required.

Dr Derek Greatorex, CCG co-chair, said the project was a “no brainer”: “It was by far the most convenient robust approach and it meets the needs of the patient.

“The whole impetus of our clinical pathway groups is to improve collaboration and get over the gulf between primary and secondary care. Sometimes it does not take much of a change to make a difference.”

Reducing prescribing costs
NHS Bassetlaw CCG introduced new prescribing practices in an attempt to become more efficient whilst improving standards of care. Ensuring that best practice is followed in prescribing is a difficult and complex task. However, the CCG was able to improve prescribing practice and reduce costs.

Working in tandem with constituent practices, commissioners were able to reduce prescription costs by nearly 10% and create savings of £1.5 million. Despite the savings, patients were never denied required medication. In fact, prescribing rates for certain drugs actually increased during the efficiency drive.
CCG Chair Dr Stephen Kell said that clinical engagement played a major part in meeting set targets. “Comparing ourselves with where we should be really got our hearts and minds together,” he said.

“Having a meaningful practice-led discussion was really important. By meeting together and sharing good practice we have been able to drive down prescribing costs. Unnecessary prescribing is inefficient prescribing and not beneficial for patients.”

Dr Kell also pointed towards the relatively small size of the CCG in helping make the scheme a success. “Size is always an issue in terms of running costs but it does enable change,” he added. “The key driver for GPs is undoubtedly patients. Everything they do should be with that in mind.”

Long-term conditions
Joint working between a pharmaceutical company and Rushcliffe CCG aimed to improve COPD pathways for long-term sufferers. The project aimed to develop an integrated COPD service which covers patients from screening and diagnosis through management in the community to hospital care.

The pharmaceutical company provided a specialist COPD nurse who worked in GP practices across the region with a high rate of COPD-related emergency admissions. The nurse provided support and improved management of patients identified as high risk, whilst working alongside practice colleagues.

The CCG also introduced a number of new measures including distributing self-management booklets to patients, a subscription to Metcheck so individuals can be forewarned of any adverse weather that may affect their condition, and a commissioned clinic at a primary care centre to keep patients out of hospital.
Also, patients had access to exercise classes at a local leisure centre to improve fitness levels and increased access to pulmonary rehabilitation services that meet NICE guidelines.

The outcome of the new services saw emergency hospital admissions for COPD sufferers in the area fall below 700 in 2011/12. The year before there were more than 800 emergency admissions, with more than 900 cases in 2009/10.

Dr Neil Fraser, long-term conditions lead for the CCG, said the introduction of new services has also seen the total cost of COPD treatment fall. “The expensive thing is often the thing that is bad for the patient as well,” he said.

“GPs have championed the improvements to services and have worked closely with specialist nurses. There has been a debate and conversation with GPs about how it has developed.”

The development of CCGs in their authorisation process is being hampered by a lack of offers from commissioning support units (CSU), the NHS Alliance has said.

Dr Michael Dixon, Chair of the Alliance, said there were not enough CSUs across the country for CCGs to use – something which is creating a “bottleneck” effect.

The chair said there was a “shortage of sellers” which may influence CCGs to turn to the private sector for assistance.

In May this year the number of CSUs fell to 23 after three groups failed to pass the NHS Commissioning Board’s second ‘checkpoint’.

Dr Dixon said CCGs had anticipated a “take it or leave it” attitude when searching for a CSU but have found finding a CSU more difficult than many had imagined.

He added that if CCGs do turn to the private sector to assist their authorisation process they must be able to do so without any repercussions. “It is important that if CCGs want to look to privately-owned and run CSUs, they are afforded the flexibility to do so,” he said.

The NHS Commissioning Board said the recruitment for more leaders of CSUs is “well under way”.

A new guide to best practice by clinical commissioning groups (CCGs) highlights the success the system has already achieved.

Clinical Commissioning in Action includes examples from 12 CCGs across England where clinically-led projects have improved the quality of healthcare for patients whilst saving money.

The guide was published by the NHS Clinical Commissioners (NHSCC) – a new group formed by the National Association of Primary Care, NHS Alliance and NHS Confederation.

Group leaders admit the switch to clinical commissioning was not easy, but was “absolutely” worth it for the benefit of patients and the NHS.

The move, the guide said, has placed patients at the “heart” of the healthcare system and “services were designed to their needs”.

Examples of successful initiatives introduced by CCGs include correcting prescribing habits in Nottingham and reviewing secondary-care referrals in Northampton.

Dr Steve Kell, GP and Chairman of the Bassetlaw Commissioning Organisation in Nottinghamshire, outlined how GPs had been persuaded to reduce the amount of antibiotic prescriptions which can make patients more likely to develop Clostridium difficile infection.

Also, Dr Peter Wilcynski, interim chairman of NHS Corby CCG, explained how referrals had been reduced by a quarter after GPs agreed to review each case.

The Health & Social Care Bill has finally completed its arduous passage through parliament. In normal circumstances, the landmark of Royal Assent would provide a key moment of clarity for the future of the healthcare in the UK. But this is the NHS – and nothing is ever that simple. Whichever way you look, the health service is bedevilled by variability. NHS Alliance CEO Mike Sobanja and Cegedim Relationship Management’s David Round look at the implications of the Bill for industry in the next 12 months.

The Health & Social Care Bill has, as we all suspected it would, survived the onslaught and made the statute book. But the hard work really does start here. In truth, implementation of the reforms on the ground began many months ago – but the process will continue for some years to come. It is a time of great uncertainty for NHS and industry alike. We now have official confirmation of where we are heading, but do we really know how we are going to get there? And with health need omnipresent, what should we be doing to protect the needs of patients today as we journey towards the health system of tomorrow? The wider call is for more collaborative working between the industry and the NHS. And there is much that the industry can do to support the significant challenges its customers face.

So where are we now? And what do pharmaceutical companies, facing an NHS in flux and customer groups in transition, need to do to support the health service and drive improvements in care? At a time of uncertainty, the industry must first do two things: follow the law, and follow the money.

Following the law and the money
At the moment – in law – we still have the presence of 151 Primary Care Trusts (PCTs). These are, of course, clustering together, while alongside them a high number of Clinical Commissioning Groups (CCGs) are steadily being established. For now, however, PCTs remain legally responsible for the delivery of healthcare services in the UK – and will continue to do so until April 2013. PCTs are currently accountable for about 80% of a total NHS budget of roughly £110 billion. It is estimated that approximately £30 billion of this has already been delegated to around 250 CCGs. But whilst PCTs can legitimately delegate their powers, they cannot delegate accountability. If someone in a shadow CCG busts the budget or, worse still, a patient dies by virtue of a poor decision elsewhere – the ultimate responsibility still lies with the PCT.

The situation on the ground is therefore complicated. Power currently rests with a number of PCT clusters acting on behalf of still legal and existing PCTs, who are delegating cash and power on the ground to CCGs. In turn, the CCGs are enjoying increasing control over finances, though technically, they are not yet legally in existence.

So if the task for 2012 is to follow the law and follow the money, pharma must focus on developing its powers of local intelligence. The fundamentals are simple, but the devil is in the detail. The law tells us who is technically responsible, the money tells us who has been delegated the power and the pound. The £30 billion question for pharma, however, is: where has the money been delegated? And the answer, of course, varies from locality to locality.

Developing the knowledge: think local, and national
And so the industry is playing a new game called ‘Spot the Commissioner’. To compete, pharmaceutical companies – and in particular their field-based professionals – need to build and maintain knowledge of local circumstances that, to a large extent, they’ve not previously had.

The move towards a localised health service is a direction of travel rather than an absolute. Moving forward, the industry perhaps needs to view the NHS as a healthcare system that operates within a national framework, but with more local decision-making. The balance of power between local and national is dependent upon which aspect of the healthcare service, and which therapeutic area, is being discussed. NICE provides a good example. In theory, the statutes require that funding is made available for technology appraisals as formal TAGs within three months of NICE making a declaration. But the reality is that whereas NICE doesn’t have to consider affordability, local decision-makers do – and therefore exactly how they implement that will inform their local decision.

As such, pharmaceutical sales professionals need to keep one eye on the national scene and one eye on the local scene – and apply that knowledge to their individual therapeutic area. They need to think very hard about how any national decisions will affect their product at a local territory level. The promotion of pharmaceuticals has moved beyond the traditional sequential sale – it is now much more sophisticated. This sophistication is only likely to increase in the future. An example of this will be the introduction of Health and Wellbeing Boards. These are already establishing under the umbrella of local authorities and will bring together interests from a wide variety of other groups: employers, magistrates, courts, local authorities etc. These will have a significant influence on local health services.

Variability: process, progress and prescribing
In such a changing and dynamic customer marketplace, the challenge of playing Spot the Commissioner becomes ever more difficult. Ironically, the only one constant is the prevalence of variability. There is variability right across the system, particularly in terms of progress around the health reforms. For example, there are local areas adjacent to one another where one locality has seen significant lawful delegation of powers to CCGs, while its neighbours have seen very little. This variability is likely to continue for some time – beyond the point where CCGs are authorised as official legal bodies. Authorisation itself is not a simple ‘yes’ or ‘no’ – it may be conditional. A conditional authorisation may mean that a CCG has power to make decisions over some things, but not others. A CCG may, for example, be authorised to commission acute services locally, but not mental health services.

At a wider level, variability in local progress with NHS reforms is surpassed by the even more significant issue of variability in care across the UK. The introduction of the Atlas of Variation in November 2010 has brought the issue into much sharper national focus and highlighted areas where progress can be made. There is, of course, variability in every disease area. Here are two very different examples. For patients with type II diabetes, the likelihood of suffering a lower leg amputation as a result of the disease is greater in the South West of England than it is in the South East. On the other hand, around the issue of cancer referral times, there is huge variation across the country in terms of GPs referring patients to secondary care for earlier diagnosis. The latter is an example of variability in health care – the former is a great illustration of variability in health outcomes.

Addressing inappropriate variability is a key priority for the NHS. And it is an area where the pharmaceutical industry can help make a real difference. Pharma companies could start by looking at the variability in the prescribing of their own products. If they can identify where that variability is and draw it to the attention of the health service locally, they will be better placed to offer support to help address it. The industry could consider undertaking Health Equity Audits to generate disease-specific data to support commissioning. For example, if you are a sales professional, what could you tell a customer about how your therapy is used in terms of its distribution among social classes, poor or rich and ethnic groups? What can you say about its relative prescribing across geographical areas? This is key information. It’s likely that there will be all kinds of variability going on that the industry could be helping the NHS address – and in doing so, it will also drive the market. By combining publicly-available prescribing data with activity data and other readily-available metrics, companies can improve their sales and marketing strategies by providing customers with the best information to help inform commissioning decisions.

The value of data
Robust data and information is the lifeblood of good commissioning, and good commissioning is the lifeblood of good health outcomes. At present, few, if any, commissioners will have complete and comprehensive access to the right data on which they can base critical commissioning decisions. But, in a collaborative environment, many would be willing to work with the industry to help create that evidence-base. As the NHS restructure unfolds, pharma can be a credible source of information for commissioners – though probably only one of a number of sources. Increasingly the health service will seek to identify data itself, and the Atlas of Variation is a good example of that. Increasingly, there are good examples of joint working where parties have come together and delivered results. In a collaborative era, wracked by challenge and change, the industry and the NHS have a responsibility to develop that relationship further.

Pharma can certainly emerge as a valuable partner to the NHS as it moves through its transition. But the generation and communication of robust and relevant data will be key to progress. In the game of Spot the Commissioner, the best sales professionals will be those who understand the local situation, understand what is driving it and align their key messages so that they are seen as part of the solution, not part of the problem. Undoubtedly, access to good data will underpin everything.

Mike Sobanja is CEO, NHS Alliance. David Round is General Manager, Cegedim Relationship Management.