Jim Easton has formally stepped down from his role as National Director: Transformation at the NHS Commissioning Board and National Director for Improvement and Efficiency at the DH.

The former QIPP boss has departed to take a role in the private sector with Care UK.

The experienced Easton said it had been a “privilege” to work for Sir David Nicholson at the NHS CB and the DH in recent years leading the QIPP agenda.

Mr Easton has served in a number of high-profile NHS roles in a career which has spanned more than a quarter of a century. He has previously served as the Chief Executive of South Central Strategic Health Authority and as Chief Executive of York Hospitals NHS Foundation Trust.

But after a successful career within the public sector his decision to quit the NHS shocked many when it was first announced back in mid-October.

Easton said the opportunity to work for Care UK was “too good to miss” and would enable him to practise “the things I have been preaching over recent years”.

“I am looking forward hugely to the new challenges and opportunities,” he said.

“Working alongside remarkable colleagues, I have led the work to improve efficiency and quality across the NHS. I am delighted to have played my part in successfully delivering the challenge to date and creating a platform for the progress to continue.

“In recent months I have also had the pleasure of being part of establishing and developing the new NHS Commissioning Board. This really has been a great opportunity to help shape the NHS of the future and transform the way we care for patients.”

The QIPP role Easton has left will not be filled by the Commissioning Board. Instead, his responsibilities will be divided between four other national directors and SHA leader Sir Ian Carruthers. Sir Bruce Keogh’s medical directorate will be responsible for a new NHS improvement body; Bill McCarthy’s policy directorate will be responsible for strategy, including medium-term QIPP strategy; Jo-Anne Wass’s HR directorate will be responsible for the new Leadership Academy; and Ian Dalton’s operations directorate will be responsible for productivity improvement.

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.

Nearly half a billion pounds will be cut from the NHS drugs budget as part of the QIPP savings agenda, according to a new DH report.

Forecasts included in The Quarter, a report which reviews NHS QIPP targets, predict that up to £477m will be saved from the prescribing budget by April 2013.

Savings will be generated by a number of treatments losing patent protection in 2011/12 allowing the NHS to purchase cheaper generic alternatives.

AstraZeneca’s Seroquel (quetiapine) and Pfizer/Eisai’s Aricept (donepezil) are two products used throughout the NHS which recently lost patent protection. Pfizer’s Lipitor (atorvastatin), one of the biggest components of NHS drugs expenditure, came off-patent in May and will also contribute to the savings.

The report shows that the NHS saved £1.2bn in the first quarter of the financial year and is on track to meet its £5bn savings target this year. Cutbacks on drugs spend are predicted to be the second biggest saving behind efficiencies coming from acute services.

The expected £477m savings is down on the £700m saved on the medicines bill the year before – when the NHS made £5.8bn of savings through the QIPP agenda.

Jim Easton, one of the most senior people in the NHS, looks set to resign from his roles at the NHS Commissioning Board and the Department of Health.

It’s believed that Easton will quit the public sector and take over as the managing director at Care UK, an independent private provider of health and social care.

The NHS CB confirmed that Mr Easton has “been approached” about a new role but could not comment further until the move has been approved in line with DH business rules.

Easton currently serves as the Director of Transition at the NHS Commissioning Board and as the DH’s National Director for Improvement and Efficiency.

In recent years Easton has played a pivotal role within the NHS. He has led the Quality, Improvement, Productivity and Prevention (QIPP) agenda since 2009. QIPP aims to help the NHS makes huge efficiency savings as part of the Nicholson Challenge. However, he recently criticised certain NHS organisations for using the QIPP agenda as a means of cutting costs without incorporating service redesign.

Before the move can be completed there is expected to be a series of negotiations and discussions around the timing of Easton’s departure. The switch also has to be formally agreed in line with rules governing the transfer of public sector staff to private companies.

“Because this would be an outside appointment, it is subject to approval in line with the business appointment rules for senior Department of Health staff moving to new roles in the independent sector,” said a Commissioning Board spokesperson.

“In Jim’s role at the Department of Health, as National Director for Improvement and Efficiency, the rules apply for a two year period after leaving. Therefore, we cannot say any more before an application to take up an outside appointment has been considered under those rules.”

Care UK were in negotiations earlier this year about a potential takeover at George Eliot Hospital in Nuneaton.

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.

Royal Bolton Hospital has been given a temporary £13.5m loan to help pay the foundation trust’s bills and wages.

The bail-out was issued after discussions between the Trust’s new chairman David Wakefield and NHS Bolton Commissioning Group.

Dr Wirin Bhatiani, Chairman of NHS Bolton CCG, said the loan was “designed to be a short-term, in-year measure and will run in parallel with the development of longer-term measures and solutions”.

The money will be issued to the Trust between September and December. However, it is unclear who will fund the cash advance. Talks are still ongoing with the hospital to assess whether the funding will come from Bolton CCG, the DH, Monitor or other sources.

The Foundation Trust’s finances were placed under scrutiny by Monitor earlier this year. The health watchdog intervened in the running of the trust when it replaced Cllr Cliff Morrison as chair after finding finances had “deteriorated significantly”.

At the start of the financial year the trust had a deficit of £1.9m but is still expected to save £20m this year, and £50m over the next three years to meet the QIPP agenda.

But Dr Bhatiani said the most important is to help the trust “with its financial shortfall to make sure it continues to function normally”.

“Discussions will continue about how to get this money back,” he said.

“We have to look at the Bolton NHS pound. The CCG is under the same obligations as the Foundation Trust to deliver a financial balance at the end of the year.”

Two new directors have been appointed to the NHS Commissioning Board Authority.

Steve Fairman has been appointed as the Director of Improvement, Development of QIPP. Felicity Cox has joined as the Local Area Team Director for Kent and Medway.

The two both come from NHS backgrounds. Mr Fairman is currently the Director of Improvement and Efficiency at NHS South of England. Ms Cox currently serves as the Chief Executive for NHS Bedfordshire and Luton PCT Cluster.

The appointments come after the Board admitted last month it was struggling to fill all of its vacant posts ahead of it becoming fully functional in April 2013.

A spokesperson for the board said it was a “complex task” developing the organisation and revealed it faced challenges in its recruitment drive due to issues such as delays in organisational design and trade unions challenging the transition process.

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.

Addressing performance levels of GPs who do not provide value for money will improve the standards of primary care in poorer areas, a senior DH advisor has said.

Sir John Oldham, National Clinical Lead for the QIPP agenda, called for clinical commissioning groups to tackle performance levels to counter under-resourced primary care services.

He said improving standards of primary care doesn’t necessarily involve investing huge sums of money but “looking at what return we get on existing investment”.

The GP advisor was speaking after he chaired an international review of primary care standards. The summit found that the majority of countries required investment to drive improvements.

Sir John acknowledged that funding was unlikely in England at a time when the NHS is challenged with making £20bn of efficiency savings. But he did say that the NHS Commissioning Board and CCGs should challenge underperforming doctors.

“We need to make sure provision in less well-off areas is as good as in well-off areas,” he said. “Most of us recognise the minority [of poor GPs] need tackling, not least to make sure patients receive a good level of care, but also to make sure they are contributing to CCGs’ commissioning aims.”

How does the NHS Operating Framework influence pharma’s engagement with the NHS?

Economics continues to dominate the healthcare headlines. There has been much conjecture in recent weeks about NHS spending and how crucial promises of a ‘ring-fenced’ NHS budget appear to have been broken. Treasury statistics show that frontline spending on the NHS has increased by £3.4 billion since last year. But opponents claim the £1.6 billion surplus reported by PCTs and SHAs in 2011/12 has not been ploughed back into the health service – breaking David Nicholson’s 2010 vow that ‘every penny’ saved by the NHS would be reinvested in patient care. The DH says the surplus is being made available in the 2012/13 budget. With the NHS facing up to the realities of the ‘Nicholson Challenge’, the political debate over healthcare spending will run and run.

Operating Framework

The latest NHS Operating Framework clearly outlines the spending plans for 2012/13. It confirms that SHA/PCT surpluses will continue to be made available during 2012/13 and final year-end surpluses will be carried forward to the NHS Commissioning Board in 2013/14. PCT surpluses are expected to be made available to the relevant local health systems in future years. Conversely, PCTs carrying a legacy debt will be required to clear it during the year. Incoming CCGs will not be responsible for PCT legacy debt but they are expected to work closely together to ensure the situation does not arise.

PCT recurrent allocations will grow by at least 2.5% in 2012/13. PCTs are required to set aside 2% of their recurrent funding for non-recurrent expenditure. SHA clusters will hold these funds, with PCTs required to submit business cases to access them. The cost of organisational change during 2012/13 will need to be met from the 2%.

Tariffs and incentives

The framework outlines developments to the payment system in 2013, to incentivise the realisation of QIPP efficiencies and drive the quality and integration of services. Payment by Results has been expanded to encourage best clinical practice and better patient outcomes. Best practice tariffs are extended to:

• Incentivise more procedures being performed in a less acute setting
• Incentivise same-day emergency treatments where appropriate
• Increase the payment differential between standard and best practice care for fragility hip fracture and stroke
• Promote the use of interventional radiology procedures

Quality improvements are also incentivised in areas such as adult mental health, chemotherapy delivery, HIV services, podiatry, trauma, maternity care and paediatric diabetes. CQUIN is also being developed to provide a stronger incentive to deliver QIPP objectives. The amount providers will be able to earn for incremental quality increases above the standard contract will rise to 2.5% – across all standard contracts. Existing national goals for VTE risk assessment and responsiveness to the personal needs of patients will remain. In addition, two new national goals are introduced:

• Improving diagnosis of dementia in hospitals
• Incentivising the use of the NHS Safety Thermometer

Planning and accountability

The final chapter of the Operating Framework outlines the accountability arrangements for the final year of transition to the newly structured NHS. In 2012/13, the DH will continue to work through SHA clusters to hold PCT clusters to account – handing the baton for accountability over to the NHS Commissioning Board in April 2013. The framework warns that NHS organisations must improve the quality of services provided through the year, while delivering transformational change and maintaining financial stability – with under-performance likely to include ‘intervention from the centre.’
In 2012/13, the key accountability arrangements are:

• The current statutory framework – where SHAs and PCTs remain the statutory units of accountability
• The NHS Constitution – securing patient and staff rights
• Contracts between commissioners and providers
• CQC – regulating NHS providers
• Monitor – ensuring Foundation Trusts are meeting their terms of authorisation and delivering against priorities

Transition plans

The transition to the newly structured NHS is a dominant theme throughout the 2012/13 Operating Framework, and measures to plan for it within the current accountability arrangements are clearly articulated. In fact, given the ambitious nature and close proximity of the reorganisation, details around the planning arrangements for the final year of transition are surprisingly brief.

‘As the industry waits for clarification of individual CCG plans, broader strategies designed at PCT cluster level are already available.’

According to the framework, PCT clusters are each required to develop an integrated plan for the period 2012/13 to 2014/15. The plan should have a clear focus on quality and the national priorities outlined in the Operating Framework. The narrative should be supported by ‘data trajectories for each PCT’, and bring together elements around QIPP, finance, activity, workforce, informatics and transition to the new structure.

Shadow CCGs must support the plan, so they have a strong base on which they can develop their own planning for 2013/14. Likewise, the integrated plans need to reflect the outcomes of local Joint Strategic Needs Assessments. As with the NHS Outcomes Framework, emphasis is placed on integrating all care sectors – with PCT clusters urged to ensure that the public health transition elements of their plan are supported by local authorities.

Implications for pharma

The Framework stated that all PCT clusters’ integrated plans needed to be prepared – and approved by SHA clusters and the DH – by the end of March 2012. These plans are of major importance to pharma. They will contain vital information on the priorities, population needs and long-term ambitions of local health organisations. With the four-wave process to authorise 212 CCGs in England well under way, further data on the specific needs of individual local health organisations will emerge in the coming months. The requirement to publish Commissioning Intentions, updated JSNA and a whole variety of other forward-looking documentation as part of the authorisation phase promises to provide pharma with a comprehensive view of its market environment at the local level. But as the industry waits for detailed clarification of individual CCG plans, broader strategies designed at PCT cluster level are already available.

At a time when finances across the NHS are being squeezed yet the bar for quality and clinical outcomes is being raised, insight into the challenges facing key customers is a valuable commodity for medical sales professionals. The transition of the NHS to a new structure can be a catalyst for proactive medical sales professionals to improve their environmental monitoring, and significantly develop their understanding of customer need. The challenge for the industry is to ensure that key account managers speak in the same language – the same currency – as the customers with whom they seek to engage. The nature and scope of that currency is defined in national documentation such as the NHS Operating Framework and NHS Outcomes Framework, and within the vast local plans that are emerging as the NHS transition gathers pace. And well beyond it.

Success is about finding a common currency with your customers. The clues are out there.