The Government’s controversial shake up of the NHS resulted in more than 10,000 workers being made redundant, new official figures show.

Information in the DH’s people tracker report showed that 2,394 redundancies were made in 2012-13, 2,100 in the year before that and an estimated 5,600 throughout 2010-2011. An additional 3,841 left the NHS on their own accord.

Initial estimations by the DH in January 2011 expected around 16,000 redundancies and a further 3,600 staff to leave the health service during the reforms.

These figures have since been acknowledged by the DH as uncertain but the report hailed a “successful people transition process while minimising redundancies and maximising the retention of essential skills.”

The report adds there may be more redundancies to come from commissioning groups as a result of reorganisation.

However, further job losses were avoided as 34,204 jobs from organisations such as strategic health authorities and primary care trusts were moved to new bodies, such as NHS England.

David Flory, Chief Executive of the NHS Trust Development Authority, has said the current reforms have left the NHS without the management capability it needs.

Over 40% of senior NHS management professionals have lost their jobs or quit in the last few weeks, he said, and the result is the greatest “loss of experience” he has seen in healthcare.

Senior roles in clinically or financially challenged organisations (including hospitals) are getting harder to fill, he said, and the NHS no longer has enough people with “the requisite capability”.

Speaking to the Health Service Journal, Flory said that filling such roles was a major priority for the NHS Trust Development Authority.

The formal abolition of SHAs and PCTs on 1 April followed a year of their functions being wound down, with staff leaving in great numbers. NHS England claims its “running costs” have been reduced by 50% compared to the old system.

“The scale of the change and loss of experience is greater than I’ve seen in any reorganisation before,” Flory commented.

He also warned that “challenged” hospitals increasingly lacked leadership as their number increased. “In that sector the evidence shows us we have not got enough people with all the requisite capability.”

Coming at a time of increasing concern among doctors about the effects of provider competition on NHS services, Flory’s comments will be seen by many as showing that the Government intends to let struggling NHS providers be taken over or replaced by the private sector.

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.”

This month John Pinching is in the big smoke with Crucell’s high-flying city slicker Kate Evans. She has an almost Dickensian ‘rags to riches’ tale to tell – forced to wash pots in order to make ends meet, Kate had a ‘road to Damascus’ moment, and now she’s one of the industry’s shining stars. What better way to kick off the festive season?

A frosty winter’s morn, Oxford Circus (exit 8, to be precise), I meet Kate Evans (right) – resplendent in an aquamarine cardigan – and we alight to a nearby hot beverage purveyor. This ain’t called ‘Coffee Break’ for nothing, dear reader. Realism is essential – we do actually go ‘for coffee’. Having said that, Kate orders a tea, shattering the illusion. I, true to my word, request a latte. The checkout girl seems a bit stroppy, but we proceed with the interview, we are professionals after all...

What do you think of the new mag? It was very eye-catching when it came through the post, which is a good thing, because usually it gets shoved on a pile. It looked different, therefore I read it. It was fun, more relaxed and sharp.

Thanks, the cheque’s in the post. So, Kate, what’s your story?  I was born and brought up in Middlesbrough and went to university in Durham. I got a 2:2 and was mortified; I cried for an entire day. I thought I’d never get a job, but I’ve realised that it’s actually your personality and drive that get you through, not what’s on your degree certificate.

Where are you based now? I arrived in London two years ago when I joined Crucell. My mum still thinks it’s another country, but I had to go and see what it was all about. I go into the office a couple of days a week in High Wycombe and the rest of the time I’m out meeting people. I prefer to be on the road, speaking to the NHS payers at the coal face: finding out about how the reforms are affecting them and how we can work together. I’m nationally based, so I go wherever people want to talk and engage in interesting projects!

How did you get into pharma? After uni I got a position as a peptide chemist, which after doing a Biomedical Science degree seemed the job of choice. It was based in the north east and we were making synthetic proteins for pharmaceutical research and development. After about a year of doing that I was ready to leave the North East and I got a job at Nottingham City hospital as a tumour immunologist researching how to create a blood kit which could detect breast cancer earlier than a mammogram.

What happened to make you change career direction? I used to chat with the reps who came in to sell pipettes and lab equipment to us. Talking to them was the highlight of my day and I used to think, ‘What am I doing every day, just staring down a microscope?’ What they were doing seemed much more ‘me’. You got to chat to people..  At the time I had to work in a pub during the evenings in order to pay my rent. That was when I became obsessed with becoming a pharmaceutical rep.

How did you get your big break? I started trying to find a rep job, but a couple of companies said you’ve got no sales experience, ‘go and work in a call centre.’ There was no way I was going to do that. Eventually I got into the industry through Innovex and worked with them for two and a half years selling MSD products. From there I went on to various positions at Sanofi Pasteur, MSD, and then on to Crucell in 2010.

How is the relationship between NHS and pharma changing? There is still a lot of mistrust stemming back to the era when everything was about a hard sell. Now you have to be able to sell a value proposition, focusing on the new NHS targets. It’s much more about ‘how we can help you with your care pathway, reduce health inequalities and improve patient outcomes’.

What is the best way to ensure relations continue to improve in the future? The key for pharma is deciding who you actually send to the Chief Executive of a CCG, because a Key Account Manager in one company may be very different to another, and some have only ever covered primary care. It is important to understand the whole local health economy and its needs. You need to have at least read the CCG strategy plan, and understood how your product can link to helping them meet their QIPP and QOF targets. I was very passionate about this at the recent Pf Local Insight Forum: many of the people in that room didn’t know what a Joint Strategic Needs Assessment (JSNA) was. In any other business you wouldn’t go and face a client if you knew nothing about what they do. Other feedback I get from customers is that they want someone who can make a quick decision, not someone who has to go back to head office and get agreement.

Have you established some good partnerships with public sector organisations? My own personal experience of working with PCTs has been very rewarding. The uptake of flu vaccines can be low due to various health inequalities, such as transient population, reduced access to clinics, and language barriers. Using local hospital data, you can start to build a business case about how a project may improve vaccination uptake and therefore potentially reduce hospitalisations. It is important to tailor any project to the needs of the local health economy as each has different requirements. I have worked with NHS, pharmacy and other private providers in these ventures. As well as improving patient care, the projects aim to improve uptake and therefore increase the overall market in the process. It shows you can be commercial and still be part of the NHS’s agenda.

You seem passionate about your work. Vaccines, whether they’re paediatric, flu or HPV, have saved millions of lives worldwide and that’s why I’m so passionate about this area. The highlight for me was being chosen by Crucell Global to visit Bangladesh in June this year to see their vaccination campaigns and how money is being put back into developing countries that don’t have a recognised health service. Since merging with Janssen this year it has been very interesting to widen my horizons and apply my skills to other disease areas. I also contribute to the NHS intranet blog for the company, keeping everyone up to date with the reforms.

What other changes excite you? It’ll be really interesting next year to see the emergence of companies like Circle Health, who have already started to fulfil contracts on behalf of the NHS, easing in the whole ‘competition element’ of reform. NHS hospitals are advertising for marketing and business development managers, perhaps because they won’t necessarily get all the referrals from primary care, given that there are some really impressive ‘Any Qualified Providers’ out there.

You’re clearly a bit of a mover and shaker, what does the future hold for Kate Evans? Everyone always wonders where they will be in five years, but I just take opportunities as they come along. As the NHS changes, so will the jobs within pharma. Companies will soon need specific people to handle joint working, for example, and I am sure more even more niched jobs will start to appear as the new NHS goes ‘live’ in April 2013.

Do you have a good work/life balance? In the days when I was winning Rep of the Year in consecutive years, the ratio was more work/work! I don’t stay on the computer until midnight any more; however, sometimes when deadlines are due, work can still start to eat into personal life. I have learnt over the years how to manage my time more effectively; it’s just part of the job. You’ve got to have relaxation time in order to function properly.

A vital aim of the NHS reform act is to reduce the amount of time patients spend in hospital beds. Paralympian Bethany Woodward is the perfect example of what can be achieved by getting treatment at home, avoiding unnecessary surgery and reaching personal goals. With three major athletic medals – you can’t argue with the results.

We meet in an upmarket hotel in London, where she is about to attend an awards ceremony. In previous Paralympic years this situation would probably not have happened. In a few short months the world has changed its attitude to disability forever.

It’s been pretty hectic since those halcyon summer days, but Bethy – who is wearing that iconic Stella McCartney tracksuit – has loved every moment. “It feels like a dream now,” she reflects.

Her charm, confidence and winning smile makes her a natural under the spotlight. It all seems so effortless, and yet, getting to this point has been the result of incredible determination.

While still a baby Bethany was diagnosed with cerebral palsy (CP). From the beginning, however, her parents – who are both senior NHS nurses – insisted on positivity. “I wasn’t diagnosed until eighteen months, when I started to crawl round in a circle,” says Bethy. “There were chances to have surgery to stretch my Achilles, but my parents were anti-operations. They didn’t want me to spend years in and out of hospital. Instead I relied on massages and walking.”

Run way
Bethy has always refused to hide behind her condition. “I’ve always tried to look at what is possible rather than what isn’t,” she says. “I was abseiling down the side of a mountain at three. I’ve never looked at my disability as something that will hold me back.”

During a blissful childhood she started to take up running after seeing the Paralympians at Athens 2004. It quickly became obvious that she had something special and, by the age of 17, she left home and headed for London to start a career in professional athletics.

“For me the hardest part was showing people my disability,” she remembers. “I didn’t expose it that much outside my safe circuit of people, but I can’t hide it on the track, where it is laid bare to everyone. Showing people that I’m proud to have CP and love my disability is really important. I wouldn’t change it for anything.”

Fast tracked
Before the Paralympics Bethy had rapidly climbed the rankings and at the World Championships in 2011 had claimed gold in the 400m. As the New Year unfolded, however, it became clear that while her speed was improving, her endurance was suffering.

She made a difficult decision. Rather than continue with 400m, she opted for 200m. Ironically, it is actually because of CP that Bethy has become such a versatile athlete, medalling at three different distances.

“I couldn’t carry on doing 400m,” explains Bethy. “I changed to the shorter distance and within a week I went from not being in the Paralympics to qualifying as a European record holder. I had a goal and I wasn’t going to lose sight of the dream I had for seven years.”

Passing the baton
One of the most gripping moments during the Games came in the aftermath of the women’s 4×100m relay final (T35–38). After receiving the baton smoothly from Olivia Breen, Bethy ran a magnificent second leg, before delivering a masterful changeover to Katrina Hart. The girls were in a glorious position to claim some precious metal, when suddenly Hart and Jenny McLoughlin got in a pickle with their exchange. The nation held its breath while officials checked whether the baton had changed over legally.

“We weren’t aware what was going on, because they were quite far away,” Bethy recalls. “When I passed the baton I thought ‘we’re on to a winner now’. We had no idea that there was a problem and were lapping up the glory. Can you imagine if we were running round and suddenly it came over the public address system that we had been disqualified?”

Fortunately they were inside the zone and Bethy was able to pick up her first Paralympic medal which, she confirms, is “bigger than a Wagon Wheel.” The time had come for the 200m.

One moment
“I was not coming out of the arena without a medal,” she said. “I was ranked number one and I wanted gold.”

On the morning of the race, however, Bethy’s condition meant that she wasn’t quite firing on all cylinders.
“There was a huge gap between the heat and final so I went for a sleep, but the thing about CP is that it is completely unpredictable. When I woke up my legs just weren’t there,” she explains. “You train really hard, but you can’t work out whether it’s going to be a good or bad day. Three races in under 24 hours is hard for anyone, but especially people with CP.”

At this point Bethy transports me back to the Olympic stadium with a dazzling description of her race.
“You couldn’t get complacent. The level of competition was fierce. I went on to that track and everyone was looking at me. This was my race, my stage, my town. I was nervously waiting in the call-up room, but as soon as I was out on the track calmness came over me. My family were there and my two brothers were watching me run for the first time. I ran on pure adrenaline and once I started to kick, pushed on by a mask of noise, I knew I would have a good finish. I loved every second, and took as much as I could, because I’m never going to see anything like that again.”

Para-mazing
Since being inspired by the Paralympians in Greece, eight years before, Bethy has witnessed the astonishing development of the Games, while also taking a great interest in Paralympic history.

“In Atlanta [1996] they were actually taking the Olympic village down when the Paralympics started!” she tells me. “In Athens there was only 15 minutes of coverage. Beijing had a full crowd, but it was free. In London two million tickets were sold, coverage was constant and there was global interest.

“This has resulted in a society-wide shift in perception. It was a real shock to be recognised as elite athletes. I’ve had children coming up to me and saying that they were inspired by me and now want to take up sport. People have changed their opinions and that will be the legacy.”

Bethy then quotes David Cameron: “The disability drifted from view and the sports person appeared.”
I conclude that this is possibly the first time that I have wholeheartedly agreed with the Prime Minister!

Building blocks
In preparation for the World Championships next year Bethy recently relocated to Loughborough with her partner Lee Doran – the javelin thrower who was controversially left out of the GB Olympic team for London 2012.

The pair will now train together at the same facilities, as they start the long journey to Rio 2016. Lee’s disappointment at not qualifying for the Olympics has served as an inspiration to Bethy who was able to rely on his support throughout the Paralympics.

“He’s incredible,” says Bethy. “He had a week when he was upset, but picked himself up and has been the most positive guy in the world. He’s my hero.”

Bethy’s burning ambition now is to break records and take home two golds from Brazil. After that she would like to become a speech therapist for the NHS. “I could go and earn a fortune, but I’d rather use my experience to change people’s lives,” she says.

I think it’s safe to say, she’s already done that.

After taking a couple of photos, we exchange farewells. Reflecting on our meeting I realise that Bethy is actually the epitome of progress: of what can be achieved by people regardless of their circumstances. NHS reform wants to change our attitudes but, as a society, the process of reforming has already begun.

Everyone in pharma is talking about key account management – but what does being a KAM mean for the sales executive?

What is key account management all about? Perhaps an anecdote will help...

A travelling salesman was on the road and stopped in a small Somerset town. There appeared to be no hotel and the local pub had no rooms available. So he drove out to the nearest farm and knocked on the door. An ageing man answered. The rep explained his problem and asked if the farmer had any rooms available. “Sure,” the old man said. “My 19-year-old daughter normally lives here but she’s away at college, so her room’s free.” The rep nodded and turned back to his car. “Hang on,” the farmer said. “I said there’s a free room.” “I’m sorry,” said the rep, “I’m in the wrong joke.”

The point is that a traditional sales rep has a well-defined script, a known role, within which certain messages and behaviours are taken for granted. The rep just has to make contact and deliver the message. That’s why he or she is the butt of so many jokes. It’s also why the traditional sales role is disappearing from our information-charged world of informed customers and organisations that make decisions on a committee basis.

Read the joke again and think of it as a metaphor for a modern business relationship.  The farmer’s spare room stands for the technological and human resources the customer can draw on. The farmer’s daughter being in college stands for the customer’s new education and range of business contacts.

To employ a technical metaphor, if the traditional sales executive is a plug looking for a socket, the key account manager is a USB flash drive from which a wealth of complex information can be downloaded. The KAM is not only addressing a plurality of customers but representing a plurality of company perspectives: sales, marketing, research, finance and management.

You’ve heard of cloud computing. Key account management is cloud selling – a way of bringing together the best elements of your company’s business strategy with the key aspects of the customer organisation’s business strategy. That classic business cliché, my people will talk to your people, is at the heart of KAM.

Meeting the family
Key account management assumes that the individual customer belongs to a complex buying environment – he/she is influenced by a range of people and uses a range of information resources. The appropriateness of this model to the NHS is obvious – and while the current NHS reforms affect the structure and workings of key healthcare accounts, they certainly do not dilute the need for such accounts. The KAM has to work with the purchasing system by identifying, and building relationships with, its most sensitive points of contact.

Identifying the decision making units within the customer organisation and working strategically to maximise your company’s impact on them is half of the battle. The other half is directly or indirectly bringing the key elements of your own company into contact with the customer organisation. This is where new technology comes into its own: nothing will make connections better than well-presented information that conveys the richness and immediacy of your business case. Tablet computers and smartphones also make the co-ordination of KAM within your own company swifter and easier.

As many pharma companies have found out, simply creating a KAM role in your sales team and expecting that to make all the difference is foolish. KAM is a function of the whole company – which seeks to meet the needs of patients via the health systems that provide treatment. The product reaches the patient via a treatment pathway that the health system develops according to its clinical and financial priorities. That pathway and the reasons for it are what the company needs to understand and change.

Looking after people
Pf spoke with Paul Curbbun, National Key Account Manager at Rosemont Pharmaceuticals. Before taking on his current role, Paul was National Hospital Manager for the same company. Before that, he was working in FMCG and other sales sectors – where KAM has been prevalent for two decades. So Paul is the KAM who came in from the cold.

On how his working life has changed, Paul says: “My life hasn’t got any easier or any harder. The only thing I’ve cut down slightly is the mileage. I’m at home more than before because I tend to use home as my office. For instance, this morning I’m spending two or three hours at home preparing before going out. There’s a lot more reports to put together as well as analysis of sales.”

On the changes in his customer base, he observes: “As NHM, I was seeing everybody – pharmacists, nurses, doctors, therapists. That’s all gone now, and what I’m seeing is mainly the buyers from the key groups, from specific retail groups to wholesalers. A lot of what I’m doing is building up business partners.”

What KAM is all about, he argues, is looking after customers: “Nothing feels better than when you’ve asked for something and you get that something. It’s about not letting people down. It’s truly looking at their business and your business and linking the two together for the benefit of both.”

That contrasts with the traditional pharmaceutical sales role of hammering the product and the marketing message. The key account manager needs to identify opportunities and develop solutions, using the company’s product portfolio to optimal effect. “Whatever the account needs – it’s that simple.”

Don’t be a stranger
Rosemont Pharmaceuticals specialises in oral liquid medicines for people who have difficulty with tablets. Their products include a formulation of the diabetes drug metformin. With a clear USP and well-defined patient population, surely this is a case for traditional product-based selling? By no means, says Paul: “It’s critical that when a patient needs an alternative, a patient gets an alternative. So from a key account point of view, you can make sure our products are where they need to be, so that patients get the right medicine and, most importantly, there is continuity of supply.”

For the sales professional, Paul states, the difference between KAM and their previous approach depends on how well they did the latter. “If you’re making calls for the sake of it, just to tick a box, obviously that’s a long way off – but if you’re going into an account with complete business focus, asking what it needs, closing the loop whenever an opportunity arises, you’re well on the way to a KAM role.” Sales professionals who analyse their sales and construct a business-focused customer database are also showing KAM awareness.

For the sales manager, the key to effective KAM is empowering the sales team to manage and take ownership of their accounts while guiding them to optimise their work as a team. KAM is not a solo activity. Paul remarks with some bafflement: “Something I could never get my head around was the fact that you often had four or five people selling the same drug over the same area. If you were devising a business model tomorrow, that would certainly not be it.”

In fact, KAM is so integral to modern business that it’s worth asking why the pharmaceutical industry avoided it for so long. The answer lies in its assumption of a difference in professionalism and consciousness between seller and buyer. For decades, pharma regarded its customers as business-naive people fixated on the patient relationship. Hence the adoption of ‘persuasion’ techniques such as NLP.

Times have changed, and bad business habits now carry too high a price. As the NHS – with its emphasis on cost-effectiveness and generic prescribing – becomes more like a business, and the industry – with its emphasis on patient-centred medicine and disease area knowledge – becomes more like a doctor, a shift from sales transactions to commercial relationships is essential for both. KAM is pharma’s only way in from the cold.

Around £3bn of NHS funding has been returned to the Treasury over the last two years, the Government has confirmed.

A spokesperson for the Treasury confirmed that the DH underspend in 2010-11 totalled £1.9bn. It also recorded an underspend of approximately £1.4bn in 2011-12.

A spokesperson for the Department of Health said the savings came as a result of “reduced inefficient spending” and reductions in “bureaucracy and IT”.

The billions returned to the Treasury come during an era of austerity for the NHS. It has been tasked with saving £20bn by 2014-15.

The £1.4bn returned last year comprised £866m revenue funds and £577m in capital funds, a Treasury spokesperson confirmed. The year before £1.2bn was returned in revenue funds and a further £700m in capital funds.

The Department of Health said that despite the billion pound returns, frontline services had actually risen by £3.4bn in 2011-12. Of the £1.4bn which DH failed to spend in the last financial year, only £316m has been carried over for it to use in 2012-13 – of which the Department claims has been used to “fund vital projects across the NHS to benefit patients.”

The train ride towards a new commissioning landscape will reach its final destination next April, but is already encountering leaves on the track along the way.

It’s been another eventful few weeks as the commissioning structure continues to take shape. On Monday 1 October, the NHS Commissioning Board (NHS CB) was finally formally established as an independent body with executive powers and exceptional responsibilities. But it will have to wait until April 2013 to take on its full range of responsibilities.

Professor Malcolm Grant, NHS Commissioning Board Chair, said the formal establishment was a “new phase
in the history of the NHS”. Sir David Nicholson, Chief Executive of the Board, called the new responsibilities the Board now holds a “once in a lifetime opportunity to do things differently”.

The transition completes a hectic twelve months for the Board. Having only been established at the end of October last year, it has played a fundamental role in the Government’s vision to modernise the health service as outlined in the Health and Social Care Act. Arguably its main and most important task, before it takes on full statutory responsibilities next April, has been to assist in the development and authorisation of more than 200 evolving clinical commissioning groups.

As you would expect, this has not been an easy process. Alongside the introduction of clinical commissioning, it has also been given the responsibility for authorising Commissioning Support Units
(CSUs), who will assist clinicians in the procurement of certain services. While this may seem a routine task compared with the authorisation of a raft of CCGs, the Board has been criticised for the time it has taken them to appoint managing directors for the CSUs when clinicians are finally in a position to tender services.

The Board has also issued its response to the Government on the draft mandate for its NHS care objectives. Professor Malcolm Grant agrees the mandate is “fundamental” to the Government’s vision of a ‘liberated NHS’. However, he urged David Cameron and Health Secretary Jeremy Hunt to be “ambitious” in searching for new opportunities to focus on the “outcomes that matter to patients and the public.”

Professor Grant said that the “critical tests” of the mandate will be whether newly empowered CCG leaders can address and analyse the mandate and then say ‘‘Yes, this gives me the necessary freedom to address the needs of my local population.” Grant added that the mandate “provides a unique opportunity to make this happen.”

The Commissioning Board has also been informed by the Department of Health of an initial set of specialist
services it will be expected to commission nationally. Although the central powers for commissioning have now been transferred locally, the NHS CB will still retain responsibility for certain services which are defined as treating rare and uncommon conditions and illnesses. The 38 specialist services, which were selected by the Clinical Advisory Group for Prescribed Services, include:

• Specialised Cancer Services (adults)
• Haemophilia and related bleeding disorders (all ages)
• Cystic Fibrosis services (all ages)
• HIV/AIDS treatment and care services (adults)
• Specialised Mental Health Services (all ages)
• Morbid Obesity Services (all ages).

A final set of regulations will be established later in the year on which services will be commissioned nationally – following a consultation between the DH and the NHS CB on the initial recommendations.

Board under fire
But it hasn’t all been clear sailing for the NHS CB. Alongside being accused of delaying the authorisation of certain CCGs because of its stuttering CSU MD recruitment drive, the Board has admitted that it has failed to recruit a significant number of individuals from ethnic minority backgrounds. Jo-Anne Wass, HR Director, admitted the Board’s recruitment data did “not make easy reading”.

Questions have also been raised about the huge variation between clinical commissioning groups’ internal staff levels when compared to support service organisations. Critics have argued that CCGs will be forced to rely heavily on support units after analysis showed huge variations in staffing levels. Recent estimates from the DH show there are 4,200–6,300 staff employed by CCGs. Commissioning support units are expected to employ around 8,000 people.

Dame Barbara Hakin, National Director for Commissioning Development, has also been put under the spotlight by the General Medical Council. The GMC has commenced an investigation after a complaint against the commissioning director, who allegedly placed United Lincolnshire Hospital Trust under unnecessary pressure in 2009 when she was Chief Executive of the now disbanded East Midlands Strategic Health Authority. It’s claimed that waiting times and A&E targets were prioritised ahead of patient safety, despite warnings the trust was over capacity. Depending on the outcome of the investigation, the GMC may decide to take no action, issue a warning, refer Dame Barbara to a fitness to practise panel where she may be ‘struck off’, or decide on undertakings to allow her to keep her registration.

Commissioning Groups
Yet despite the disparity in numbers, evolving CCGs appear to be in good shape. Following the successful scheduling of all of the wave one applications, the NHS CB confirmed that all 67 CCGs in the second authorisation wave had submitted their applications on time. In fact, every proposed CCG is now involved in an aspect of authorisation with the Board – be it a 360° stakeholder survey, a desk-top review, a case study or a site visit.

However, the authorisation process has been delayed. Initially the Board moved the ‘waves’ back by a month each. It subsequently moved the waves back by an additional month, meaning all CCGs will now be authorised by March 2013.

CCGs have also learnt when their final commissioning budgets will be confirmed. Commissioning Groups will have to wait until December to find out how much money they have been allocated to organise local services to meet the needs of their residents. The budgets will be decided using a system called the Fair Shares formula, which analyses the unique circumstances practices face and the health and wellbeing
of local populations.

Commissioners have aired frustration about the amount of ‘red tape’ they face when trying to organise new local health services. NHS Clinical Commissioners, who represent CCGs across the country, say bureaucracy is hindering doctors in their attempts to redesign new services. Dr Charles Alessi, Chair of the National Association of Primary Care, said there was an “overwhelming number of rules and regulations” which were having a significant impact on commissioners.

Supporting units
But it seems the frustration many commissioners have aired at the slow rate at which CSUs are being established may soon be coming to an end. David Stout has left the NHS Confederation to lead CSUs in Essex and Hertfordshire; Tim Andrews has also been given joint responsibilities at Cheshire, Warrington and Wirral CSU and at Merseyside CSU; Derek Kitchen will lead Staffordshire CSU and Lancashire CSU. Dr Leigh Griffin has also been appointed as the MD of Greater Manchester CSU – meaning only two of the 23 CSUs are still awaiting a permanent managing director.

While the NHS Commissioning Board is readily completing the authorisation process for CSUs it has recently been distanced from employing their support staff. The NHS Business Services Authority has agreed to employ some 8,000 staff during the hosting period up to 2016. The move means that although the NHS
CB will provide oversight and direction to CSUs it will not be the legal employer of CSU employees to avoid conflicts of interest. The new distancing arrangements were welcomed by the Board, who said it would help CSUs “develop appropriately as organisations in their own right.”

After confirming four lead CSUs to provide communications and engagement services around the country last month, the Commissioning Board will now focus on assisting support units to provide services and help to CCGs through the authorisation process, to ensure they are as individually autonomous as possible, to
help CSUs develop to become specialist suppliers and to ensure units seize opportunities open to them.

As the NHS reforms continue to evolve it would seem the commissioning landscape is far from being complete. It’s going to be a busy few months.

Is QIPP really about ‘doing more with less’?

The NHS Quality, Innovation, Productivity and Prevention (QIPP) Challenge was launched in March 2010 as a strategy to facilitate major cost savings within the NHS, in response to the impact of the global recession. The principle of QIPP was that given the need for austerity budgeting, serious planning and rethinking were needed to ensure ‘smart’ cost-cutting that did not harm patient outcomes. The QIPP agenda was about identifying solutions that held together the four key principles, reducing overall costs by making interventions more timely, efficient and effective.

The new Government’s NHS reforms promised to facilitate QIPP by empowering local providers and commissioners to develop the best solutions for their communities. However, the economic pressures on CCGs and Foundation Trusts within the new system, combined with the ‘Nicholson challenge’ of cutting £5 billion out of the NHS budget in each of four successive years, have meant that the dominant theme of QIPP at a local level is cost reduction.

The first full year of QIPP (2011–12) delivered savings of £5.8 billion against a target of $5 billion. However, reports of NHS rationing and ‘postcode prescribing’ have proliferated. QIPP was devised as a strategy to combine two goals: the shift towards community-based healthcare and the urgent drive towards NHS cost-cutting. Is that still the agenda, or have the pressures of NHS reform reduced its four principles to one: reducing expenditure? Is QIPP really about “doing more with less”, as Andrew Lansley claimed, or is it just about doing with less?

A new healthcare paradigm
The DH booklet introducing the QIPP challenge in March 2010 set the context: “The NHS needs to identify £15–20 billion of efficiency savings by the end of 2013/14 that can be reinvested in the service to continue to deliver year on year quality improvements.” The booklet placed emphasis on improving quality while reducing overall costs through strategies such as early intervention, improved infection control and home-based care. Its authors included Jim Easton, then National Director for Improvement and Efficiency. The DH described a series of QIPP ‘workstreams’ it was setting up to help clinical teams and NHS organisations “improve quality and productivity across care pathways”. The first of these related to care of long-term conditions, urgent care and end-of-life care. Further workstreams would examine safety challenges, such as pressure ulcers (bedsores), and ‘right care’ issues such as referral management and identifying “low-value treatments” (later to become controversial issues).

The authors called for “a collective response at local, regional and national level” to address the QIPP priorities. These included early diagnosis, primary and secondary prevention and patient self-management. The need for “better partnerships between primary, community and secondary care to support people with long-term conditions” was emphasised. QIPP extended from the “daily clinical practice” of individual HCPs to “the wider care pathway”, the booklet said. Each SHA had its own QIPP lead and innovation lead, and was establishing an online regional ‘quality observatory’ and Innovation Fund to help clinical teams improve quality and productivity.

These ideas were illustrated by case studies where local NHS organisations had developed better and more affordable healthcare solutions. These included the use of an electronic system to ‘re-engineer’ blood transfusion, reducing waste and improving safety; and systematic guidance on antibiotic prescribing to reduce rates of C. difficile infection. These solutions all involved using teamwork and sharing information to make the best use of available resources.

The booklet ended on a warning note: “If we do not respond to this challenge there is a real risk that the need to cut costs will overtake our best intentions to improve care for our patients.” More than two years later, the crucial question is: has QIPP averted that outcome or brought it closer?

Innovation is ‘core activity’
In June 2012, Nicholson’s annual report claimed 2011/12 had been “a remarkable year” for the NHS. He highlighted the contribution of local initiatives to maintaining service quality while cutting costs. Austerity would dominate the NHS “for the foreseeable future”, he said. However, the innovation agenda promoted by the previous Government’s Office for Life Science and revived by the current Government in December 2011 would engage dynamically with that challenge: “Innovation has to... become the core activity of the NHS.”

His report went through the elements of QIPP, noting achievements in each area. Quality achievements highlighted included: in cancer care, the achievement of key treatment standards across all eight performance measures, as well as improved early detection figures; and in stroke care, better access to specialist stroke units and faster treatment of people with transient ischaemic attacks. Community-based asthma services in South East Essex were used as an example of a successful local initiative.

The brief section on innovation focused largely on the use of technologies in the community, including telehealth and home dialysis. The preventative care section emphasised the growing role of health visitors, and drew attention to the success of a national screening campaign for risk of venous thromboembolism (VTE) with prophylactic drug treatment given where needed.

In the productivity section, Nicholson noted QIPP savings of £5.8bn and praised the “modest reduction in activity levels” across the NHS – placing these in the context of the QIPP Long-term Condition Workstream, which aims to reduce unscheduled hospital admissions by 20%, reduce hospital stay length by 25%, and maximise the role of “supported care planning” in helping people to manage their own health. However, no reference was made to the rationing of procedures or the cuts in hospital nurse staffing.

Milestones or millstones?
A recent Health Service Journal report on the DH’s QIPP tracker indicates that the PCTs (soon to be abolished) plan savings worth £13bn nationwide between now and 2015, with £4.5bn of this to be achieved through the 53 local QIPP plans. The planned savings are front-loaded: £3.8bn this year and £3.6bn, £2.9bn and £2.6bn in the next three years. However, only £2bn of the planned QIPP savings are currently being achieved on schedule, and only six local QIPP plans are on track with all of their workstreams.

According to the tracker, productivity gains are the main objective of most local initiatives. Common features include the redesign of care pathways for long-term conditions, including diabetes and COPD, and the development of integrated care teams for dementia patients. However, many local plans have the single goal of reducing the cost of services – for example, South of Tyne and Wear PCT notes as an objective: “reduce price paid for Gateshead Health Foundation Trust older people’s mental health service”.

John Appleby, chief economist of the King’s Fund, commented that this emphasis on savings denied the original point of QIPP: “to improve value to patients”. He also said there was no evidence of the money saved being reinvested in future services, which was a key principle of the original QIPP agenda. The Audit Commission has since reported that the NHS has £4bn in “uncommitted finances”: cash reserves created by aggressive cost-cutting. Mike Farrar, Chief Executive of the NHS Confederation, has argued that this money needs to be invested in community and primary care.

Jim Easton, the NHS Commissioning Board’s Director of Improvement and Transformation, warned in July that too many NHS organisations were relying on spending cuts without any element of service redesign. The “deeper change” of shifting healthcare to the community was not being undertaken, he said, and
QIPP was becoming a “label” for “cost improvement plans”. As a result, the QIPP savings of the past year would be very difficult to repeat. Instead of building a new healthcare model, the NHS was just cutting
parts of the old one.

Easton has since announced that the Board will fund a new innovation body to deliver a “system-wide” response to the QIPP challenge. From April 2013, the new organisation will replace all existing NHS innovation and technology adoption bodies. He anticipates that it will “provide hands-on support for great models of care” developed within and beyond the healthcare sector. However, his resignation has cast a shadow over these plans.

According to the King’s Fund, 27 of 42 NHS finance directors it surveyed believe there is a high risk that the NHS will fail to meet the ‘Nicholson challenge’. A key question for industry, and for patients, is whether QIPP can help the NHS deliver on the more important challenge of transforming healthcare to meet the
changing needs of the population.

The pharmaceutical market in the UK is changing quickly. By April next year just over 200 Clinical Commissioning Groups will have completed the approval process and will be operational. This will dramatically change the customer landscape for pharmaceutical companies and also demand changes in engagement strategies. This, in turn, will necessitate changes in the behaviours of individuals responsible for that engagement (such as Market Access Managers, Key Account Managers and Sales Representatives).

Pharmaceutical companies are continually restructuring in an attempt to keep pace with the rate of change. However, one of the key problems they face is assessing whether their current workforce has the talents and skills to address these new challenges. It is certainly the case that some companies are finding a lack of flexibility and adaptability within their workforce to support the change process.

Critical talents
Given the fluidity of the market environment and to be in a position to proactively respond to it, companies must address the critical talents required by the workforce and start to assess for these talents during the recruitment process. These include two particular talents which are of vital importance, but are often currently not assessed for. These are:

• Adaptability (or flexibility/agility)
• Learning mind set.

Adaptability
Individuals with this talent will respond well to changing demands. They flourish in environments that reward responsiveness and do not require a highly formalised or routine structure with lots of rules and regulations. They also have the ability to recognise current or future anticipated changes and adjust their attitudes, beliefs and behaviours to cope with them.

Learning mind set (Learner)
People with this talent demonstrate a great desire to learn and want to continuously improve their knowledge and skills set. They will also be more likely to understand the changing nature of the marketplace and the need to learn how to engage with new types of customers.

Many Sales Representatives in the Pharmaceutical Industry are being asked to radically change how they work and to start engaging with customers using key account management principles. To perform this
role effectively, more knowledge of the customer and the marketplace is required. There is also the need to change behaviours and attitudes that may have suited the more traditional role they fulfilled previously.
Those representatives with adaptability and learner talents are more likely to succeed than those without them. These talents are now required across the whole structural chain – from Representative to Manager,
to Leader, to Technical Consultant, and across the wide and varied roles within the engagement process. The ability to learn and adapt is now critical within Pharma/Healthcare and beyond.

Selecting for adaptability and learning mindset
As with any other talent, predicting who will be adaptable requires a variety of assessment techniques, including:

• Occupational Personality Questionnaires (OPQs) that assess cognitive ability including reasoning,
  thinking and problem solving
• Interviews to assess personality factors, including results orientation, openness to new experiences and willingness to try new things
• Specific tools which assess mental toughness and the candidate’s ability to confidently cope with change, difficulties and new environments.

Similar approaches can be used to assess whether candidates have a learning mind set. In his book A Collection of Articles on Achieving High Performance in Teams within Pharma and Healthcare, Tony Swift,
a colleague at Apodi, stresses in the article entitled ‘Moving on up’ that successful executives must take charge of their own personal development and not rely on the employer to spoonfeed all learning.

Frankly, it is easy to spot this. Those executives who blame the employer for lack of development, or who are ‘too busy’ to dedicate time to learning, almost certainly do not have a learning mind set. Compare this to the ‘learner’ mind set, which sees individuals organising their working day to set aside time to ensure they keep up to date with developments in the marketplace, new
innovations and the latest practices.

Promoting adaptability and a learning mindset
Whilst it is important for individuals to take responsibility for their own development, this in no way absolves the organisation from also playing its part in developing a culture where adaptability and a learning mind set become ingrained. Whilst reviewing recruitment practices is, of course, a good start, unfortunately cultural change is more complex than this. Cultural change requires fundamental shifts in behaviours and these can be encouraged by:

• Bringing new people into the organisation with the appropriate talents, as above
• Changing the organisational structure
• Short term objectives, incentives and controls that demand adaptability and learning.

In my own organisation, we have realised that it is critical for most of our employees to have an in-depth understanding of the NHS and how our services can best be applied for the benefit of our customers in such a rapidly changing environment. To ensure Apodi promotes this, the company is:

• Running regular workshops that are focused on ‘Understanding the changing NHS and the Apodi proposition and how to apply it to the new market economy’
• Guidance to all individuals on how they can keep updated on all key developments through the use of the web, social media and other sources of information. Whilst guidance is provided, it is stressed that ultimately responsibility rests with the individual for their own personal development.

Stability is a dangerous illusion
For a lot of people, the Pharmaceutical Industry has provided a stable career over many years. For example, there are many Sales Representatives who have had a successful career fundamentally doing the same job in the same way and often for the same employer. Whilst there will always be a need for Sales Representatives within the industry, the number has fallen and will continue to fall. And for many, the role itself will change and demand the acquisition of new skills and knowledge.

Some companies are addressing the need to change rather quicker than others. Those that are slow to act may be creating a situation where some employees still feel they are operating in a relatively stable environment. This may be a dangerous illusion because it is almost guaranteed that the changing environment within the industry will impact on most employees – and probably sooner rather than later.

Given this situation, companies will increasingly be looking for employees who have the adaptability skill to cope with change and fundamental to this is a learning mind set. We believe this is relevant to all employees looking to advance with their current employer and to those looking for opportunities elsewhere. Both short-term and long-term career planning in the new age requires employees having a CV that clearly articulates the capacity to adapt and an in-depth understanding of the changing industry environment. For people with these talents, they should be able to look forward to a varied, rewarding and long-term career within the industry.

Jan Cox is the Resourcing Director at Apodi and can be reached on jan.cox@apodi.co.uk.