The Care Quality Commission (CQC) should use a ratings system like the Ofsted system for schools, according to a Government-commissioned expert report.

The new ratings system could be applied to GP practices and social care services within two years, and later to hospital services.

Think tank the Nuffield Trust emphasised that the system should be “sector-led” and allow input from patients, making it a key facilitator of patient choice.

This would not be a revival of the previous government’s ‘star ratings’ for hospitals, which were abolished in 2004 as being narrowly target-driven.

The BMA has praised the report’s commitment to appraisal of hospital services rather than entire hospitals.

The Nuffield Trust review, commissioned by Health Secretary Jeremy Hunt, said the CQC could develop the new ratings system given “stability from disruption over a period of time”.

There is “a clear gap” in the existing NHS performance appraisal system, the report said: no process exists to give patients clear information about the quality of available care providers.

Presenting the report, Nuffield Trust Chief Executive Jennifer Dixon (pictured) said ratings systems for GP practices and social care could be introduced within two years – but for hospital services, which would require individual department and clinical service ratings, more time would be needed.

The previous ‘star rating’ system for hospitals, used to help them qualify for Foundation Trust status, did not accurately reflect care quality, Dixon said.

The report emphasised that the new “sector-led” ratings system needed to be integrated with existing appraisal systems, and that the CQC would need support from other NHS stakeholders to develop and implement it.

Sources for the ratings could include QOF indicators (for general practice), hospital records, patient and staff surveys and inspections.

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.

Financial performance related schemes do not motivate GPs and result in a drop in standards of primary care, researchers claim.

Professor Steffie Wollhandler from the New York School of Public Health warns that financially related systems are based on “flawed assumptions” about medicine, measurement and motivation.

She added that providing financial rewards for hitting set targets “changes the mindset needed for good doctoring”.

The DH’s Quality Outcomes Framework currently rewards doctors who hit set targets. But Professor Wollhandler said that while more “straightforward manual tasks” are completed, complex cognitive tasks are overlooked.

“A growing body of evidence from behavioural economics and social psychology indicates that rewards can undermine motivation and worsen performance on complex cognitive tasks, especially when motivation is high to begin with,” said Professor Wollhandler in an editorial with the BMJ.

“Highly detailed prescriptive contracts may be perceived as controlling and may undermine the intrinsic motivation crucial to maintaining quality when nobody is looking.

“Offering financial incentives to doctors, rather than enhancing their intrinsic motivation, may reduce their desire to perform an activity for its inherent rewards (such as pride in excellent work, empathy with patients).”

The General Practitioners Committee (GPC) has questioned the move to create a composite indicator for diabetes believing it may have an adverse affect on patient care.

Measures to conduct nine separate checks in each diabetes patient will demotivate doctors, lead to increased referral rates and infringe on rights to refuse treatment, the GPC warns.

Dr Laurence Buckman, GPC chair, said in a letter to NHS Medical Director Sir Bruce Keogh that a single indicator may lead to “unintended consequences”.

The Department of Health recently asked NICE to consider a composite indicator for inclusion in the Quality Outcomes Framework (QOF) after an investigation found only half of patients received the nine existing separate checks.

But the GPC argues that if the new indicator were to be introduced it would “have consequences”, especially where patients did not wish to engage in specific checks or attend altogether.

“A composite indicator that defunded practices of the whole quantum of diabetic QOF funding – designed to fund the process, not just the outcomes – risks demotivating practices completely and would almost certainly have the unintended consequence of increasing diabetic referrals,” said Dr Buckman.

He added that a “regimented tick-box check” would be “extremely counterproductive”.

But Sir Bruce responded by defending the switch. “The QOF is currently not incentivising practices to increase the number of their patients who receive all nine care processes that are the hallmark of good diabetic care delivered to patients,” he said. “If one or two are missed, patients are not getting the care they should receive.”

NICE has proposed 16 new indicators for inclusion in the 2013/14 Quality and Outcomes Framework (QOF) and rheumatoid arthritis (RA) as a new clinical area.

The recommendations include four for RA, two for men with diabetes, plus indicators for COPD rehabilitation and hypertension.

Dr Gillian Leng, Deputy Chief Executive and Director of Health and Social Care at NICE, said the potential indicators “can make a real difference” to improve standards of care.

QOF is a voluntary incentive scheme that rewards GPs for implementing systematic improvements in care for patients. It operates through a points system which rewards doctors for their performance against the indicators.

Indicators for RA include GP practices creating a register of patients aged over 16, and patients being assessed for cardiovascular risk and fracture risk.

In men with diabetes, indicators focus on offering advice on erectile dysfunction and on available treatment options.

The final ‘menu’ of indicators will be decided by NHS Employers and the British Medical Association later this year.

A single diabetes indicator will be created for the Quality Outcomes Framework (QOF) by the DH after an investigation found only half of patients received the nine existing separate checks.

Findings from the National Diabetes Audit for 2010/11 suggest that suspected diabetes patients are not being thoroughly checked for the condition by GPs.

Sir Bruce Keogh (pictured), NHS Medical Director, has written to NICE asking it to replace the current QOF indicators with a “composite indicator measuring the proportion of patients who received all nine of the processes”.

In the letter, Sir Bruce also called for the Institute to review the range of “target measurements and associated payment thresholds”.

“We hope to work together (with NICE) and with the BMA and other stakeholders to improve the QOF and support ongoing improvements in quality and outcomes for patients,” said a DH spokesperson.

The new indicator – which would be worth more than £5,000 – could be included in the 2015 framework.

The General Practitioners Committee (GPC) filed a complaint over the data used in the audit. The DH has now launched an investigation into the complaint with the outcome expected in September.

A local information strategy is key to successful account management. The data is out there. Rhiannon Thomason explains how turning information into insight is all about context.

Despite reforms that appear to encourage decision-making and accountability at a local level, the UK health service remains a national one. The Health & Social Care Act actually strengthens the centralised power-base and, via the NHS Commissioning Board, issues a series of top-down directives that will cascade to a local level for implementation. Rumours of the death of the ‘N’ in our NHS are grossly exaggerated. But for Key Account Managers across the UK pharma industry, what happens at a local level is perhaps the prime focus. There is much talk of the need for ‘local health intelligence’. It is indeed a vital commodity. But it is important to draw the distinction between information and insight. The former is readily available. The latter is hard won and impossible to achieve in isolation. In the battle for local health intelligence, context is King.

The NHS is awash with data. Nowadays there is much more information available and the health service itself is increasingly placing useful data into the public domain. Examples such as QOF data, Joint Strategic Needs Assessments, HES (Hospital Episode Statistics) data, the Atlas of Variation and Public Health observatories provide a rich seam of information from which sales and marketing professionals can develop appropriate local messages. They combine to form a complex matrix of information. The challenge for KAMs is interpreting it and understanding what it means in their disease area and in their locality. There is variation right across the system.

In primary care, QOF data has become increasingly important. NHS customers are being tasked to reduce unnecessary hospital admissions, and the financial incentives from a local practice perspective are significant. But as the transition towards Clinical Commissioning Groups continues, practices know that they cannot work in isolation and that they must prove to the wider organisation that they are achieving their targets.

For the industry, QOF indicators have become a catalyst for improved customer engagement. Proactive sales professionals are no longer targeting GPs with messages based only on the clinical benefits of their products. They are instead identifying key local decision-makers and attempting to demonstrate how their product can impact a service, reduce hospital admissions, save a locality money and improve patient care.

Clearly, QOF data has become a strong lever for account managers to understand how their product can help customers meet their targets. In isolation however, the data can only take you so far.

When used in combination with other available information, a much more powerful package of metrics can emerge.

Sales professionals need to build the bigger picture of what is going on at a local level, to understand how their products can make a difference. This depends upon drawing together all the various strands of information, and developing value propositions based on the local context as a whole.

• How is each local health economy constructed? Which organizations are operating within each locality? What are the roles/responsibilities of each and how do they engage with one another? Who are the key stakeholders?
• What is the community profile? How many patients are there? What are the deprivation and ethnicity breakdowns?
• What is the patient pathway? What services are provided, by whom and how are patients managed?
• What is the cost of hospital activity? How much does each group of patients cost each locality?
• What are the outcomes? How much is each locality spending and how well are they managing each group of patients? How can the outcomes be measured?

The trick for pharma is to be able to use all of this information intelligently, in combination. Much of it is publically available, but without the knowledge and understanding of how it translates into what you are trying to achieve, it could, in a worse case scenario, send the sales professional in the wrong direction.

Variation in care
In a complex environment where context is everything, it is important not to lose sight of the bigger picture on a national scale. Many of the challenges being faced by local commissioners on the ground are around the treatment of diseases identified as national priorities. The implementation of commissioning plans at a local level largely cascades down from the key domains laid out in the NHS Outcomes Framework. The challenges manifest themselves in the local variations in care that are widely highlighted as being in need of redress. Once again, these local variations – if intelligently assessed – provide pharmaceutical companies with a powerful market access opportunity. Companies that can demonstrate that their products, not just their messaging, are aligned with local need will significantly increase their chances of uptake.
A good example of how the national agenda is driven by addressing variation in care at local level, is the treatment of diabetes.

Diabetes – a mini case study
The national picture
An estimated 3.8 million people in England have diabetes, with 2.45 million QOF registered patients. This is forecast to rise to 4.6 million by 2030. Diabetes and its complications costs the NHS around 10% of its annual spend. £725 million a year is spent on diabetes medication (8.4% of NHS drugs spend), and an additional £600 million is spent on diabetes-related hospital activity. An estimated 80% of the NHS’s £9.8 billion UK diabetes bill is spent on treating diabetes complications. It is predicted that diabetes will cost the NHS £16.8 billion by 2035.

National and local initiatives
As part of QOF, practices are to be encouraged to provide lifestyle advice and annual glucose checks to everyone judged as high risk from the age of 25 – even those with normal HbA1c levels. NICE is piloting new QOF indicators that promote tight cholesterol control in diabetes.
The introduction of insulin pumps instead of injections, as well as educational programmes such as the DAFNE (Dose Adjustment For Normal Eating) course are good examples of local initiatives to combat diabetes.

Local variation
NHS Hampshire has the highest number of diabetes patients on the QOF register (54, 761). Hospital admissions (inpatient, outpatient and emergency attendances) are costing NHS Hampshire £3.7 million each year – one of the highest of all PCTs. However, its cost per thousand patients is low – ranking 113 of all PCTs. It also has the lowest death rates from diabetes. Therefore, although it has the highest number of diabetes patients, NHS Hampshire appears to be managing its patients well.

NHS Kingston has one of the highest diabetes spend per thousand patients in England. Compared to other PCTs in its SHA, it also has a higher number of Finished Consultant Episodes, longer lengths of stay, higher emergency admissions and the lowest elective admissions. Compared to NHS Hampshire, this suggests  that NHS Kingston could be managing its diabetes patients more optimally.

Lessons for pharma
The diabetes example outlined above provides a clear indication that a one-size-fits-all approach to pharmaceutical sales and marketing will no longer work. The apparent variation in care between two diverse PCTs highlights that every local health economy has different needs. A diabetes KAM working in Hampshire could not relocate to Kingston and challenge stakeholders there in the same way, with the same proposition. The situation, and the opportunity, in each PCT/CCG is totally different. The ensuing approach must be similarly distinct.

A local information strategy is critical for Key Account Managers engaging with today’s NHS. Understanding local dynamics is critical, and the information to facilitate this is increasingly within reach. The key is joining it all together and placing everything in context. It’s a mixture of local and national. Top-down directives issued at national level are providing important indicators by which local commissioners are measured, and are in turn are becoming powerful levers to help pharma develop value propositions that align with local need.

The data is out there. But success is in understanding the difference between information and insight. After all, context is King.

Rhiannon Thomason is Business Development Manager, Cegedim Relationship Management.

Maxine Vaccine considers the motives of politicians, clinicians and the pharmaceutical industry and concludes that no matter what direction you approach it from, health is never a simple issue.

My last blog, ‘Life in the balance’, provoked some interesting feedback. I had argued that the current government’s application of free-market principles to the NHS would encourage those doctors who saw what they do primarily as a business rather than as a service. An industry expert commented that a series of health policies over the past two decades, from GP fundholding to QOF indicators, have promoted the same mentality.

This of course is true. Not only are New Labour’s fingerprints all over the current phase of NHS reforms, but the medical profession has never been unified in its perspective on the relationship between health and financial priorities. Different doctors have different attitudes – or have various attitudes in different proportions. Where important decisions are concerned, most of us have mixed motives.

However, it’s rather in the nature of blogs, Twitter feeds, press releases and Parliamentary statements that we pretend otherwise. “Only one thing matters to me” is the opening clause (explicit or implicit) of almost any public statement. “I’m torn” would be bad business, bad politics and bad bedside manner... but it would, almost every time, be the truth.

So let’s be clear that when doctors say “We are motivated only by clinical priorities” it is not necessarily the pure truth. They are motivated to succeed at a professional and business level, and that may extend to practice finances. When the BMA decided to oppose the Heath and Social Care Bill it was not only on clinical grounds, but because the business proposition did not appeal despite its lucrative potential. Maslow’s ‘hierarchy of needs’ is a relevant concept here: the fear of losing control may override the desire to increase your income.

And when politicians say “Our priority is only to improve services” that is not necessarily the pure truth either. Most comment on the NHS reforms has focused on whether the Government is right to believe the new system will deliver better patient outcomes. But is that the only issue? Politicians are not doctors, and – as recent events have proved – they don’t even want to listen to doctors. It’s not cynical to see NHS reform in terms of wider political priorities for society and the economy: that is precisely how politicians see it.

There’s no doubt that Andrew Lansley would like to see patient outcomes improve. But his sense of what can achieve that does not come from expert medical opinion: it comes from the political ideology that assumed privatisation would make the rail service cheaper, safer and more reliable. At least as important, from his viewpoint as health secretary, is the priority of breaking down the national and public sector employment basis of health workers, so that local employers can set their own terms and conditions.

As for the pharma industry – well, it depends on who you talk to. Your CEO will tell you (and the media) that everything your company does is driven by a passionate commitment to making a difference for patients. The public largely believe that everything your company does is driven by the need to make a difference for shareholders. The truth is that even a humble field representative is motivated by a complex blend of factors: short-term targets, longer-term business growth, customer relationships, clinical success, public reputation and the need to laugh once in a while.

Like mixing a drink, medical sales is all about finding the right balance – and not losing your own.

Maxine’s views are not necessarily those of Pharmaceutical Field.