The NHS cost-cutting policy known as the ‘Nicholson challenge’ will be extended indefinitely beyond 2015, according to NHS England.

The Government does not expect any improvement in the economy beyond 2015, so has put in place plans to extend the QIPP agenda on a long-term basis.

The statement by NHS England’s Policy Director, Bill McCarthy, refutes Government claims that the NHS budget is ‘ring-fenced’.

However, McCarthy emphasised that the incremental cost-cutting measures that have so far been used to achieve QIPP savings will not be either adequate to the challenge or possible to keep repeating.

Instead, NHS England – through its Local Area Teams – would look at “ambitious and radical” service changes.

The LATs will need to ensure that the decisions of individual CCGs do not conflict with this national service redesign agenda, he said – further qualifying the supposed ‘autonomy’ of CCGs.

Instead of closely monitoring QIPP savings at the local level, as the DH had done before, NHS England will rate the savings plan of each CCG as ‘red’, ‘amber’ or ‘green’ based on whether it can be and is being realised.

NHS England recently published a business plan indicating that it was drawing up a framework for “major service reconfiguration”.

Malcolm Grant, Chairman of NHS England, stated recently that the next government would consider the option of charging for NHS services.

The combined statements by Grant and McCarthy suggest that a radical reduction in the availability of free NHS services is planned beyond 2005.

The NHS Commissioning Board has launched a new national operating model to commission specialist services in a bid to drive standards of care.

A national approach will deliver consistent, high quality services which will provide patients with the same standards of care provided throughout the NHS.

Ian Dalton, Chief Operating Officer and Deputy Chief Executive at the NHS Commissioning Board, said the new model is a “real opportunity to dramatically improve the way we provide services for people with rare and specialised conditions.”

Specialised services account for around a tenth of the NHS budget. The number of patients who require such services is small and facilities are located across the majority of towns and cities across England.

The NHS CB hopes the new model will improve the experience of care patients receive and allow specialist staff to be more easily recruited and levels of necessary training maintained.

Specialised services will be delivered on behalf of the NHS CB by the ten nominated Local Area Teams around the country.

Currently, there are ten different systems for commissioning specialised services across the country. The new single approach provides commissioners with the opportunity to innovate and introduce new technologies to benefit patients and improve health outcomes.

“This improved system will ensure national consistency in accessing services, reduce variation, and set clear quality standards leading to better health outcomes for patients,” said Ian Dalton.

The Board will take on the responsibility of commissioning specialist prescribed services from 1 April 2013.

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.

The NHS Commissioning Board (NHS CB) has again started the recruitment process for nine local area team (LAT) directors – after failing to fill the positions in July.

Positions for the lead roles in areas such as East Anglia, Lancashire, West Yorkshire and Kent and Medway have a salary of £140,000 a year.

The NHS CB, which is currently in process of recruiting Commissioning Support Unit (CSU) financial directors, is also conducting the final stages of the final round of appointments for CSU managing directors.

Currently, 16 of the 23 MD positions have been filled by the board. However, it is not yet known when the further six positions will be filled, meaning certain interim managers will remain in charge to oversee the majority of the CSU development period.

Alongside the LAT and CSU roles, the NHS CB is also searching for 19 directors to fill various vacancies. These include director of HR, financial control and other recently announced senior posts, such as chief analyst and director of intelligence. All 19 positions have salaries of more than 100k.

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 Authority (NHSCBA) has appointed the first 16 local area team (LAT) directors.

Six positions in the North, a further six in Midlands and East, three in the South and one in London have been filled during the first round of recruitment.

Ian Dalton, Chief Operating Officer and Deputy Chief Executive of the NHS Commissioning Board Authority, was “delighted” that “key appointments to such important leadership posts” were filled.

In total, there will be 27 local area teams – but London will have an integrated structure with one director controlling three LATs to reflect the “distinct nature” of the capital. The NHSBA hopes to complete the recruitment process “shortly”.

Appointments include Chris Long, current Chief Executive of NHS North Yorkshire and York PCT Cluster and NHS Humberside PCT Cluster, for North Yorkshire and Humber LAT in the north.

Wendy Saviour, Director of Partnerships at the NHSCBA, will lead Birmingham and Black Country in Midlands and East; Simon Weldon has been appointed to head the London LAT; and Debbie Fleming, SHIP PCT Cluster Chief Executive, will oversee Wessex.

LATs will have the same core functions around CCG development and assurance, emergency planning, resilience and response, quality and safety, configuration, system oversight and partnership and stakeholder engagement.

Senior leaders of LATs will also join health and wellbeing boards as partners.

Teams will also be responsible for commissioning GP services, dental services, pharmacy and certain optical services. Ten LATs will lead specialised commissioning, with a handful also commissioning other services such as military and prison health.

“This puts us in a position to quickly develop the local presence of the NHS Commissioning Board, building strong relationships with our partners and communities to firmly focus on driving improvement for our patients,” said Ian Dalton.

The NHS Commissioning Board Authority has published the national structure for its 27 local area teams (LATs) and 12 clinical senates.

There are nine LATs in the North of England, three in London, eight in the Midlands and East, and seven in the south of England.

The LAT boundaries are aligned within the senate boundaries, except in three cases where patient flows dictate a modified senate boundary.

The NHS CB comments that this structure is “a sustainable solution” that will establish the Board’s “definitive local presence”.

The area teams will take on direct commissioning for GP services, dental services, pharmacy and some optical services.

Specialised commissioning will be the responsibility of 10 particular LATs, whose boundaries are aligned entirely within the senate boundaries.

London will have a more integrated structure, with three LATs working to support citywide arrangements for direct commissioning and to promote service innovation.

The clinical senates – to be made up of clinicians and other health and social care professionals – will assist CCGs and Health and Wellbeing Boards by providing strategic advice and leadership for local commissioning.

The configuration of the new local NHS organisations – 212 CCGs and 27 NHS Commissioning Board local area teams – has been agreed.

The list of proposed CCGs, which replace the 50 PCT clusters, is divided into four application waves spread over the next five months.

The 27 NHSCB branches replace the 28 SHAs and represent an ‘upward delegation’ of their responsibilities.

These new commissioning authorities now cover the whole of England.

The NHSCB Authority has published the geography, names and member practices of the proposed CCGs. Once the Board is established as a statutory body, it will approve these details.

Each proposed CCG has been assigned to one of four application waves for authorisation: 35 in wave 1 (July 2012), 70 in wave 2 (September), 67 in wave 3 (October) and 40 in wave 4 (November).

The 27 NHSCB local area teams (LATs) are likely to comprise three in London and seven to nine in each of the three regions North, South and Midlands and East.

Each local team will include an overall director and medical, nursing and finance directors, as well as general managers.

According to the Health Service Journal, 28 area teams were planned – but in order to avoid comparisons with the previous 28 SHAs, one was dropped.

Around 10 LATs will commission specialised services on behalf of several other LATs, while a few LATs will take a national lead in specialised areas such as optometry and military health.

The teams will be formed from staff members appointed to the NHSCB in the coming months.

The NHSCB’s annual running cost budget has been agreed at £527m.