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.

As his working day finally comes to an end in part IV of his diary, Omar Ali discusses the new methods pharma needs to use to interact with its customers and how to ensure formulary is gained for its products.

4:15pm: DRIVING BACK TO NHS BASE CAMP – CHECKING VOICEMAILS

Request for appointment in U/C and IBD: An interesting proposition from a company aimed at payers around healthcare costs and the potential for a patient access scheme. They’re looking to set up a ‘payer round-table forum’ for all the hospital pharmacists and some PCT advisors to consider this in terms of the health economy.

Thoughts for pharma

It must be hard to see all the ‘payer’ decision makers – PCT advisers, D&T pharmacists, commissioners, budget holders – in a coordinated fashion so that they can in unison consider your proposal. Bringing together payers in a room for half a day is another way of ‘bringing the mountain to Mohammed’. The new NHS is asking for new ways of working; so why are you guys still calling ‘door-to-door’ to sell double glazing? Get real, bring the decision makers together, get round the table, thrash out the proposal. If
it costs money, then let it cost money.It will save you from wasting it on another munch-bunch GP evening,
booked for 30 people where only eight invitees turn up and listen to a key opinion leader talk about your brand on advertised slides when the PCT has already told them “it’s not on formulary”. Pharma needs to think of the different keys that will unlock the different doors. I am glad to see some companies seeing the light – whilst others have already thought up old school pharma solutions without mapping the problem.

NICE REQUEST FOR A PANEL ON ERG

A call from NICE to sit on another ERG Panel; they’ve also booked a teleconference call to evaluate a new toolkit for NHS healthcare professionals to account for tariffs and internal financial mechanisms within the external/overall healthcare costs.

Thoughts for pharma

This is a long story – please see previous article on tariffs that sometimes reward counter-intuitive funding decisions where issues around tariff, income generation and commissioning get in the way of basic healthcare economies of scale. Last week I was in Scotland and can see that the devolved nations have a far less adversarial approach to implementing new drugs due to the absence of the ‘internal market’ within both of these countries.

GP COMMISSIONER/ EVENING MEETING

A request for me to present on a White Paper to a Primary Care Forum from a CCG in the West Country – topics to include diabetes outcomes.

Thoughts for pharma

I was honoured. This was a direct recommendation from the GP consortia to present at a PCT-wide meeting. I think he feels that the PCT is pushing hard on costs of diabetes drugs, whereas the costs of diabetes complications need factoring. Locally we are having a review with one of the CCG/GP consortia on implementing diabetes prescribing and I sense the GP is torn between good diabetes care and the fact that we can’t afford good diabetes drugs. Around the UK, or certainly England, Peter Rowe/QIPP has caused a stir by recommending a direction back to NPH insulin (v.analogues) and reducing/limiting blood glucose test strips – which we are considering. This led to a frenetic and reactive pharma response, which to my mind needs tempering and rationalising. Again, the argument “What would you want for your
grandma?” doesn’t work. It doesn’t matter what I want for my grandma. That’s not a basis from which to draw up a policy on reimbursement of health economy interventions – it was tried in Oregon and it failed. I foresee difficult times here and tough decisions. I myself wouldn’t have thought we would come to the day when we started switching patients back to NPH, but it has indeed started happening. What this means for companies who i) market insulin analogues and ii) are soon to launch insulin analogues needs careful re-assessment and they need to get their payer story straight first time. It’s clear this decision does not
have the full buy-in from diabetologists and diabetes nurses. But indeed it’s the payers leading on this and the payers that will set the tone of reimbursement. Pharma needs to sort its payer story and it needs QIPP alignment, because at the moment, QIPP alignment means non-alignment with your brand.

CONSULTANT CARDIOLOGIST – REQUEST FOR D&T APPLICATION FORM/ASSISTANCE

A consultant from our Trust is applying for a new product which has just launched. The implications are not short of massive. I have already passed this onto another two directorates for consultation and strategic management. It’s going to be big, and I think this will be more than just ‘another drug’ on the formulary.

Thoughts for pharma

I generally do not see great applications at the D&T. They are usually fair to poor. Despite numerous attempts and repeated communications, consultants don’t turn up. The forms completed by pharma are obviously usually disregarded. Consultants need assistance. I will aim to support/advise, but as I sit on the D&T I am unable to fill in the forms for them. They need to run this from beginning to end. And take
ownership of the drug. Furthermore, in this case, it’s not just cardiology. I think haematology and pathology will need to be involved to the level where they could well be very annoyed at the thought of being bypassed.

4.50pm: ARRIVAL BACK AT NHS BASE CAMP

In the corridor – impromptu discussion with a consultant rheumatologist.

Thoughts for pharma

Touching base on a number of therapeutic issues that are in prescribing format, including the choice of an anti-TNF, a new patient access scheme in place, how we will manage methotrexate injection in the community, navigating a drug we are using which NICE has said ‘no’ to, and finally the closure of the denosumab story – all our PCT acute Trusts are now on-formulary, it took a fair bit of ‘round tables’, crossforum prescribing discussions and a little key I found called HRG  Code X30.9, which has framed this
drug in a whole new way. In fact, once we reviewed the issues, it was simplifying the problem which led us to the collective answer from a commissioning perspective.

Einstein once said, “Everything should be made as simple as possible, but no simpler.” In this case anyway, he was right.

Keep it real. The Matrix.

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.

In Part III of his diary, Omar Ali discusses the significance of process mapping and the wide reaching influence of health technology assessments and regulatory bodies.

1.10pm: GP CONSORTIA/CCG – RESPIRATORY ASTHMA PROCESS MAPPING & FORMULARY

I’m trying to step into the main meeting room but one of the CCG/GPs pulls me aside. It’s a mixture of a low-key signal and a discreet ‘thumbing’ to pull away from the group. He wants a quiet word and it’s clear that there are some key issues, agendas and directions that are on the table for this asthma meeting.

The process mapping event takes some four hours – evaluating everything and anything that ‘leads to an asthma admission’, followed by everything and anything that occurs after the admission and leads to discharge – which is then followed by QIPP ‘bottlenecks’, where re-admissions and inefficiencies occur.

It’s always a challenge having so many viewpoints – nurses, physicians, pharmacists, budget holders, and of course patients and carers who often change the whole paradigm when we hear about their experience, expectations and concerns around ‘choice’.

Thoughts for pharma

Respiratory is big. Whether on prescribing budgets, healthcare priorities, implementation of national guidance or QIPP streamlines. Companies haven’t yet got their act together on process mapping of care pathways, but it’s the only way to invest in prescribing up-front drugs for potential ‘return to the QIPP baseline’ over the next three to five years. Needless to say, whilst the NHS talks QIPP, pharma is getting used to it and patients are still puzzled by it.

Asthma

With so much behind National Guidance/BTS, QoF and commissioning cycles, some companies are indeed getting into the mix with Clinical Commissioning Groups and supporting process mapping. That support is vital, as not only does it bring pharma in as key stakeholders, but more importantly there is a level playing field here in the same room bringing the cause back on track.

So often in the NHS we have silo budgets chasing after silo savings. Process mapping brings us out of our silos into the bigger picture and into the ‘process map’. Seeing it happen is a wonderful thing.

COPD

Given we make such a fuss around the cost of drugs, in truth we know two things: the most expensive drug is the one that is not being taken, and the tariff for an admission for COPD at £3,400 is more expensive than the annual price of the most expensive inhaler!

So where’s the issue? It goes like this. Pharmaceutical companies come to us quoting the costs of admissions in COPD then tell us how amazing it would be to reduce these hospitalisations.

They then tell us how amazing their COPD product is and tell us that we would be crazy to not buy their inhaler, which is a fraction of the cost of COPD burden/admissions. The GPs, nurses and patients love it and want it and state they ‘need it’. Medicines Management then look like the bad guys for not funding the said branded inhaler.

4.15pm: DRIVING BACK TO NHS BASE CAMP – CHECKING VOICEMAILS

One of the big five companies has asked me to come and present to their European heads-of-country on ‘payer issues’ in the UK and the influence of HTAs.

It’s a bit short notice and I gather the VP for Europe, Middle-East and Asia will be there. Times are tough and I see this as an example of how the EU can join forces on some of the key payer issues beginning to filter through.

I have one question back to these pharma companies. What is your data on reducing these expensive hospitalisations in COPD? Because in truth, with the data, I buy the story.

In most cases pharma will then spin another story around how compliance is great, or a patient support programme is excellent. But given all the spin that has come on how much COPD costs me in hospitalisations, it’s a shame many of the companies don’t have the evidence to help me.

They have marketing but not the evidence. Show me the money. And the formulary will be yours.

Thoughts for pharma

There is no doubt that the UK is ‘different’, but I don’t imagine global HQ for any of the pharmaceutical companies readily accepting that – especially when the targets are high and sales may not be so. It sometimes takes global agencies to hear about payer issues ‘from the horse’s mouth’.

This was the quote stated to me regarding this piece of work/event. From my work abroad – at NICE I informally interact with a number of contacts in other countries who belong to their residing equivalents – I can’t stress enough the importance of NICE, the SMC and similar bodies.

The last SMC decision on pain management was quoted verbatim within two weeks by three different countries within the EU. I’m also aware from my US/value-based pricing work that when NICE rules on a drug the impact on the US healthcare system is far reaching.

Insurance companies download the information – they can’t believe NICE do all this work transparently and then leave it freely available for anyone to download – and the US agencies then use this information on deciding what percentage they will ask patients to pay.

So, if NICE say no and SMC say no, somewhere a butterfly flaps its wings and then a patient in the US, who has paid extra funds into a private insurance policy, will be told that this particular brand is not covered and that the patient will have to make an additional payment if they want the drug.

To be continued...

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.