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.

The experienced John Wilderspin has been appointed to lead the Central Southern Commissioning Support Unit.

The current National Director for Health and Wellbeing Board Implementation at the Department of Health has been recruited to the Managing Director position by the NHS Commissioning Board.

Mr Wilderspin has more than 25 years’ experience in healthcare management and has held senior roles in several NHS organisations.

Prior to joining the DH, he was a PCT Chief Executive and held a number of roles with the NHS Modernisation Agency. During the 1990s he also ran an acute hospital trust in Essex.

His appointment means that only one of the 23 CSUs across England does not have a permanent managing director.

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.

Clinical commissioning groups will learn their final budgets in mid-December, the NHS Commissioning Board (NHS CB) has revealed.

Budgets will be decided using the new Fair Shares formula which analyses the unique circumstances practices face and the health and wellbeing of local populations.

Dame Barbara Hakin, National Director for Commissioning Development, said under the formula CCGs will get an allocation based on the PCT’s previous amount “with uplift”.

Once the NHS CB has received final confirmation of its mandatory funding from the Government, it will then make the final allocations of funding to commissioning groups.

At this point it will be agreed whether the Fair Share formula will be used to determine how much additional funding CCGs may receive in 2013–14.

The Fair Share formula has been devised by a panel of independent experts. Unlike the previous system used to create PCT budgets, it takes into account the number of registered patients, diagnosed conditions of patients and issues such as birth rates and levels of mental health service use.

CCGs’ budgets for the local commissioning of healthcare will be separate from its indicative running costs to ensure money allocated for health services is prioritised. CCGs will receive £25 per head of population to pay management and administration costs.

The NHS has billions of pounds which is being unused, according to a new report by the Audit Commission.

Research into the NHS’ financial year 2011/12 discovered there was nearly £4bn in ‘uncommitted finances” after PCTs, SHAs and NHS trusts restricted spending.

The NHS Confederation said the money should be given to CCGs across England to help transform local health services.

The report revealed NHS organisations had a combined under-spend and surplus of £1.6bn. However, the number of NHS trusts and foundation trusts in deficit increased from 13 in 2010/11 to 31 in 2011/12. A small number of trusts did report improved finances during the same period.

It also highlighted the financial difficulties NHS trusts have in different parts of the country. The majority of NHS trusts in deficit were either in London or around the south east.

Andy McKeon, Managing Director of Health at the Audit Commission, said the findings show there is “financial room for manoeuvre in the future.”

“The NHS has also delivered the first tranche of its £20bn savings required by 2014/15,” he said. “While nationally the NHS appears to be managing well financially, and preparing itself for the changes and challenges ahead, a number of PCTs and trusts are facing severe financial problems.

“The Department of Health and other relevant national authorities need to focus their attention on the minority of organisations whose financial position is deteriorating, and on their geographical distribution and service standards.”

Mike Farrar, NHS Confederation Chief Executive, said the funds should be used for “big investment in community and primary care” to ensure services can meet demand in the future.

“Fundamental changes to the way we provide care are necessary if the NHS is to maintain financial balance and become more responsive to patients’ needs,” he said. “Doing this will require some difficult decisions and in some cases will require changing or closing down some services, but this can only happen if we build up the capacity in the community and in primary care to enable people to be treated at home.”

CCGs are the core of the new NHS – but are they running the game?

The emerging clinical commissioning groups (CCGs) embody a core principle of the new NHS: that commissioning decisions should be made locally, by clinicians, and be focused on community-based care. According to Andrew Lansley, the defining feature of the NHS reform is a “shift of power” from national and regional organisations to local ones, of which the CCGs are the most important.

The role of CCGs in the new NHS is both structural and dynamic. They will commission healthcare at a local level, spending £60 billion of the £80 billion NHS commissioning budget, and will hold together the relationship between patients and providers. They will also work with providers and business partners to redesign local services, and those new solutions will spread through the NHS. The CCGs will thus be the drivers of healthcare innovation.

However, given that GPs are meant to lead the CCGs, the concerns raised by many GPs about the new system are significant. Will CCGs really have the opportunity to improve care, or will they simply have to drive through spending cuts? Will they really be run by clinicians or by the private sector? Is the heart of the new NHS dynamic and responsive, or divided and unstable?

Development of CCGs

In July 2010, the white paper Equity and Excellence: Liberating the NHS spoke of “putting GP commissioning on a statutory basis” through the development of ‘GP consortia’. These new organisations, to which every GP practice would belong, would run each local health economy: they would contract providers, partner with local authorities, and be accountable to patients and the public for outcomes. They would be authorised by a new national body, the NHS Commissioning Board, which would also commission GP services.

The initial reaction of the GP community was positive. Being in the driving seat of a fast-evolving NHS, able to redesign local services for their patients, appealed strongly. However, the codification of the reforms in the Health and Social Care Bill led to growing opposition among GPs. Issues raised included the power of the Board to direct GP consortia and the requirement that consortia embrace provider competition. Above all, the deepening economic crisis made GPs fear their role would be one of rationing services, not finding solutions.

The Government’s ‘listening exercise’ did not resolve the concerns about competition and rationing, but it led to a stronger assertion of the autonomy of the consortia. An important change concerned the scope of clinical representation: the new ‘clinical commissioning groups’ were defined as including specialist consultants and nurses as well as GPs. That was a step towards the ‘integrated care’ that the BMA had highlighted as a priority.

Breaking the waves

The NHS Commissioning Board Authority, set up in October 2011, has the primary responsibility of putting in place a nationwide system of CCGs to replace the PCTs by April 2013. A total of 212 CCGs have been approved to go through the authorisation process in four waves: 35 in wave 1 (commencing in June 2012), 70 in wave 2 (July), 67 in wave 3 (September) and 40 in wave 4 (October).

The authorisation process is designed, according to the Board, to ensure that CCGs have a “strong clinical and multi-professional focus”; have meaningful patient engagement; have credible plans to “deliver the QIPP challenge”; have proper governance arrangements; are set up to collaborate with other CCGs, local authorities and the Board; and have strong leadership.

It has not always been a smooth road, however. The Board, concerned at the prospect of CCGs competing for providers of commissioning support, announced it would take over the appointment of leaders to Commissioning Support Services. One CCG has already protested that its authorisation has been delayed by this.

Another issue is lack of GP leadership. Clare Gerada, chair of the Royal College of GPs, said that only “about 25 GPs” in England were actively interested in leading local commissioning. The reason, she said, was that the “transactional” aspects of commissioning as a business did not appeal to them. 

GP-led commissioning

CCGs will be responsible for commissioning community health services (including mental health care and services for children and elderly people) and hospital care (both A&E and elective care). The NHSCB will be responsible for commissioning primary care as well as pharmaceutical and dental services. Local authorities will be responsible for public health, with the NHSCB covering certain aspects.

Collaborative working between CCGs and the other statutory organisations involved in healthcare is anticipated, but the model is not one of top-down control – rather, it is one of business partnership. The NHSCB can provide assistance or support to CCG commissioning; this may take the form of extra funding or access to staff and other resources. CCGs have a duty to co-operate with local authorities in supporting aspects of public health, including child health and mental health.

CCGs are able to buy in support from external organisations, including the CSUs whose development is currently being governed by the NHSCB. For more details on the CSU landscape. CCGs can also buy in support from the private and voluntary sectors, but will retain control of commissioning decisions. These relationships will differentiate CCGs, as some are keener than others to engage in private sector partnerships.

Commissioning of hospital services is also likely to differentiate CCGs, especially as many hospital trusts are facing financial challenges as they shift to foundation trust status. CCGs will influence the development of FTs through their commissioning strategies – for example, they may promote private providers both within and beyond FT-provided services. The acute sector will have a voice in CCGs, though its representatives on a CCG board cannot come from the local area.

The GP-led nature of CCGs is variable. Fewer than 50% of current CCG board members are GPs, and there is potential for the management of local commissioning to be outsourced. CCG boards should include a non-practice nurse and a specialist consultant, but local government are excluded.

Life after April 2013

Securing GP ‘buy-in’ remains an issue for the NHS reforms, but those GPs who support the reforms have been most active in developing CCGs. The CCG boards thus represent a more pro-market segment of the GP profession. Pharma companies may find that their CCG customers and GP customers require a nuanced and varied approach.

Each CCG will have a different mix of GPs, hospital clinicians and financial or management specialists. It will also be dealing with local health issues, which are also impacting on local government and the local Healthwatch body. Every CCG will have to find its own balance between clinical outcomes and economic success.

CCGs will also face a tension between the ‘autonomy’ stressed by the NHSCB and the need for partnership with other stakeholders, within and outside the NHS. Will this tension lead to fragmentation and paralysis, or to dynamic innovation driven by the local synergy of clinical and commercial talent? Whatever the answer, the CCGs hold the key to the success or failure of the new NHS.

Cancer patients across England may be denied essential treatment due to their GPs missing symptoms and delaying referrals to specialists, a study has found.

Figures from the National Cancer Intelligence Network (NCIN) found that some doctors are referring three times more patients than other GPs to see cancer specialists.

Sarah Woolnough, Executive Director of Policy and Information, Cancer Research UK, said the findings are “very worrying” and the process of referrals and poor practice needs to be addressed.

Official figures found that 1,000 GP practices referred more than 2,550 people per 100,000 but sent fewer than 830 patients per 100,000 for further tests.

The individual GP practice with the highest referral rate – 5,591 patients per 100,000 – was in Sefton, Merseyside; however, one practice in London referred only 89 patients per 100,000.

Unsurprisingly, PCTs areas with the highest referral rates – in the north west and south west – have the highest rates of cancer in England.

The study also found the proportion of patients who were referred that went on to be diagnosed. The ‘conversation rate’ across England was almost 11%. But this again varied and highlighted the fact that some GPs are missing essential symptoms or being overly cautious.

Professor Sir Mike Richards (pictured), National Cancer Director, said that anybody with persistent symptoms should be referred “urgently” to increase chances of survival. “Where differences have been exposed, GPs should consider their referral practices, which will help to drive up standards of care for everyone.”

The study calculated that if cancer survival rates in England matched the European average more than 5,000 lives could be saved each year through earlier diagnosis and better treatment. If survival rates matched the best across Europe, around 10,000 lives a year could be saved.

Professor Richards added that the Government has invested more than £450m to achieve early diagnosis rates and to support GPs to assess and diagnose cancer symptoms better as part of its cancer strategy.

What does the ‘single operating model’ for primary care commissioning mean for GPs?

The NHS Commissioning Board Authority’s ‘single operating model’ for primary care commissioning represents a major step in defining the relationship between GPs and the new NHS. As such, it is essential reading for anyone with a stake in prescribing behaviours and, more widely, in patient pathways.

A major question posed by the Lansley reforms is: who should commission the commissioners? If GP-led groups are responsible for commissioning secondary care, who can commission primary care? The answer, the NHS Commissioning Board, was greeted with mistrust by many GPs who asked why they needed some Big Brother watching over the job they had always done.

In addition, the passage of the Health and Social Care Act left a lot of broken glass scattered through primary care. The relationship between clinical outcomes and money, the involvement of the private sector in the NHS and the apparent fragmentation of the health service are issues that divided
the GP profession.

So the single operating model has the task not only of outlining new clinical and business relationships, but of building professional bridges. The Board tackles this challenge by saying up front that it seeks to
achieve “the right balance between national consistency and local decision making”.

Unlike earlier documents describing the infrastructure of the new NHS, Securing excellence in commissioning primary care does not list concrete developments to be in place by April 2013. Rather, it outlines a pattern of relationships that will develop from that date, when the new single operating model
for primary care commissioning becomes operative. It represents the parts of the new
NHS working together with a clear goal of outcome improvement.

The commissioning challenge
According to Dame Barbara Hakin, National Director for Commissioning Development, the new system aims to “tackle unwarranted variation and take positive steps towards raising the overall standard of primary care”. The document notes that primary care, while accounting for only 15% of the NHS budget, has a
profound role in making “preventative interventions” and influencing all the care patients receive.

The challenge of replacing “many different systems” for primary care commissioning with “a single national
operating model” without losing “vital local responsiveness”, the Board says, depends on “establishing relationships and arrangements across the new organisations” – including CCGs, whose health strategies
will set the context for primary care.

The NHSCB will be responsible for planning, securing and monitoring primary care services. Its local area teams will manage the performance of GPs and other primary care providers (dentists, community pharmacists and opticians), and will help to support providers in difficulty and deal with major emergencies.

The local area teams will support patient “choice and control in designing services that respond to their needs”, focusing on “the basic service offer” (such as early diagnosis) to reduce variations and health inequalities. Likewise, they will support the development of “local area clinical leadership teams” that draw on the expertise of all types of primary care clinicians. Finally, their focus on patient outcomes means they will look for “improvement strategies” at all times.

All together now
Most primary care commissioning will take place through the Board’s local area teams working with CCGs, local authorities and health and wellbeing boards. The Board as a central authority will “ensure consistency” and provide the framework for performance management and quality assurance. Crucially, this system involves “fewer managerial resources” and “larger geographical footprints” than the previous system. It does not remove local initiative: it just removes the SHA and PCT management layer.

At the heart of the model are the common operating procedures for local area teams, of which the most important is “to standardise the performance management frameworks and processes at practice, provider and individual levels”. Managing variability and the healthcare market are also key priorities.

Commissioning support services may also assist local area teams: emphasis is placed on the value of
business intelligence in providing “a single flow of standardised information”, and the potential for CCGs to share support for primary care development and redesign with local area teams.

Micro commissioning
CCGs themselves will work closely with the NHSCB to review the “micro commissioning decisions” made by
GPs in “each referral and prescription”. The Board says that its work with CCGs has shown they can progress effectively together towards “quality improvement” through benchmarking, data sharing and peer review. It notes further that CCGs will be able to commission integrated “wrap-around” community-based services in which GP practices can participate, with care taken to manage conflicts of interest.

The local area teams will establish relationships with a range of partners, including CCGs, Local Healthwatch, health and wellbeing boards, local authorities, Public Health England local units and the CQC. Clinical networks will feed into the primary care system “with a particular focus on early diagnosis and timely treatment”. Public health commissioners will advise local area teams on priorities for the local
population, and work with them to develop health improvement initiatives that may include primary care.

The Board concludes: “During the next three to six months, we will fully explore all the interdependent relationships critical for the operating model and take any action necessary to ensure that they will work effectively.” It encourages discussion of the model within PCT clusters and feedback on
potential improvements.

A business network
The single operating model for primary care commissioning is not so much a ‘one size fits all’ as an ‘all things to all people’. It shows the old hierarchical NHS giving way to something much closer to a business network, with shared rules and goals but different cultures. The imprecision of the arrangements described displays the will to promote clinical innovation and business
development.

The emerging structure is designed to give GPs more confidence that they will be neither isolated nor controlled. Those who need guidance and support will receive it, while others will have the freedom to change treatment pathways and business models. This will help to defuse opposition to reform in the
profession, while setting the stage for further changes.

For pharma, the new model points to the development of a complex and flexible customer network with many points of contact. Key account managers are much concerned with how primary care operates and the factors influencing it. This model shows primary care in a dynamic field of NHS and other stakeholders, responding to ideas from all sides: an exciting prospect for suppliers.

THE NHS Commissioning Board’s role in NHS reform is still widely debated. Pf looks at how it will direct the NHS of the future.

The new NHS Commissioning Board (CB) is unique in three respects. Firstly, it stands to take on more power than any arm’s length body in NHS history. For up to three years at a time, it will be entrusted by the Government to run the NHS and allocate its entire commissioning budget, without regular scrutiny by Parliament.

Secondly, it stands to hand over more power than any arm’s length body in NHS history. Of its annual £80bn
commissioning budget, £60bn will be delegated to the 212 Clinical Commissioning Groups responsible for commissioning local services. While the CB will commission primary care from the CCGs and ensure that they deliver on the NHS Outcomes Framework objectives, it will allow them to devise their own solutions and choose their own partners.

The powers of the SHAs are being delegated ‘upward’ to the CB, while the powers of the PCTs are being delegated ‘downward’ to the CCGs. The widespread concern about a potential gap in responsibility led Sir David Nicholson to say: “The NHS Commissioning Board could turn into the greatest quango in the sky. So it needs to have clinicians at its heart and the powerhouse for change in the system must be the
clinical commissioning groups.”

Andrew Lansley’s letter to the CB’s Chair, Malcolm Grant, in April about the Board’s strategic objectives stresses that its first responsibility is to make a “shift of power from national and regional organisations to CCGs, Health and Wellbeing Boards, local providers and patients.” The CB will not be a monolith within a static system: it will be a facilitator of future NHS transformation. That dynamic role is the third unique
feature of the CB, and the most important.

TAKING THE REINS

The DH plan Developing the NHS Commissioning Board (July 2011) outlines the intended structure and functions of the Board. It will have two broad national roles: to commission primary care and specialised services, and to ensure that the entire commissioning system is “cohesive, co-ordinated and efficient”.

Using £20bn of its annual budget, the CB will commission GP services and specialist health areas, including dentistry, maternity, community pharmacy and ophthalmic services. The Board will not govern the CCGs in a traditional way: it will “support” them and “hold them to account” while allowing them “freedom to innovate.” This support includes authorisation, an outcomes framework, guidance tools such as model pathways, and a means of intervening when CCGs are in difficulty.

The CB will host clinical networks to advise on specific areas of care and multi-disciplinary clinical senates to support CCG decision-making. Another key role of the CB is to lead the NHS Outcomes Framework by supporting local clinical improvement, providing “more services outside hospital settings”, improving acute care and the management of long-term conditions, and ensuring that CCGs implement NICE and other national standards.

In addition, the Board will lead patient-centred care by overseeing “the extension of patient choice and the expansion of information available to patients” and promoting both integrated care and innovative self-care.

Finally, it will develop a “medium-term strategy for the NHS” that will combine with the local priorities identified by the Health and Wellbeing Boards to provide a basis for local commissioning plans.

LEADER OF THE PACK

According to the 2011 outline, the CB will work in “partnership” with many other organisations: patient groups, healthcare professionals, healthcare providers, local government, industry and national organisations such as NICE.

The Board’s relationship with suppliers will “support its strategic approach to innovation and development” – in other words, it will play a part in the dynamic evolution of services and provider relationships.

The CB will be organised nationally around the five domains of the NHS Outcomes Framework, with a national lead for each domain. It will also divide its local teams into four ‘commissioning sectors’ reflecting the four existing SHA clusters, each with a sector lead.

The Board will take over functions performed by 8,000 people. It plans to reduce that number to 4,000 – a reflection of its ‘light touch’ approach.

RIDING THE WHIRLWIND

According to Lansley’s letter to Grant, the CB has a responsibility to “contribute to” improved health for “the whole population”, improved care and outcomes “for all patients”, and improved efficiency. Within this context, the Board Authority’s strategic objectives include “transferring power to local organisations” and “establishing the commissioning landscape”. The new NHS will then develop under its own steam, with the clinical networks and senates providing “leadership and insight rather than oversight and compliance”. The authorised CCGs will have the “assumed liberty” to design local services independently.

In addition, Lansley says, the CB will have a “vital leadership role” in enabling the personalisation of care by improving patient choice. This includes the use of personal health budgets. At the provider level, the CB will play a “crucial part” in developing a “level playing field” for competition.

In short, the role of the NHS Commissioning Board is to facilitate the evolution of a rapidly changing healthcare system. These changes will come not from the Board or the DH, but from the decisions of CCGs and their commercial partners.

The failure to reduce the cost of acute care is threatening the development of clinical commissioning groups and may lead to disastrous PCT cuts, the General Practitioners Committee (GPC) has warned.

PCTs are struggling to achieve savings via the QIPP agenda which may result in budget deficits being inherited by CCGs in April next year.

Board papers from a number of PCT clusters show that acute costs are currently spiralling out of control at a time when the NHS aims to make £20bn of efficiency savings.

In NHS Bedfordshire Cluster, acute and specialist care costs were £11.2m over budget. Overspending was also recorded at the Arden Cluster in Warwickshire and by the NHS Greater Manchester Cluster – which was deemed “totally unacceptable” in the board’s minutes.

Meanwhile at England’s largest Primary Care Trust NHS North Yorkshire and York, a £19 million deficit for this financial year will be passed on to the CCGs which will take over responsibility in the region next year.

Dr Chaand Nagpaul (pictured), GPC negotiator, said that short-term savings by PCTs are increasing future costs inherited by CCGs. “The whole rationale of (cutting) secondary care costs depends on a primary care infrastructure to absorb care in the community,” he said. “It would be illogical, counterproductive and damaging to cut primary care.”