Vaccines are the most important breakthrough in modern medicine: the jewel in the crown of the pharma industry. What can the success of vaccines teach us about healthcare and the industry’s commercial model?

Out of the virus immunity comes.

Killing Joke’s lyric uses vaccines as a metaphor for the human ability to find a positive meaning in the darkest threat. The history of medicine has shown, time and again, that every disease holds the seeds of its own treatment – but to find the answer, you have to look deep inside the problem.

It has been said that no other health initiative, with the exception of clean drinking water, has done as much as vaccines to improve public health. Medical sales professionals love selling vaccines, for two reasons. Firstly, their potential to protect the young and the old against highly dangerous diseases is beyond reasonable doubt. Secondly, the sales model for vaccines is as dramatic as its medical impact: the supplier becomes responsible for securing the immunity of a population.

Yet, on the face of it, the public might wonder what the fuss is about. Vaccines are one-off medical treatments that protect against specific infections. Many are prophylactic: they don’t work if you have the disease. They are not 100% reliable, since pandemic infections have many competing strains. And they can have harmful side effects. So why should healthy people bother?

The answer lies in the list of deadly and disabling diseases that once cast a shadow over human life, but now are preventable: smallpox, polio, tuberculosis, measles, mumps, chickenpox, typhoid, cholera, bubonic plague, rabies, tetanus, diphtheria and pneumonia. For some viral infections, vaccines are the only effective treatment.

Vaccination programmes demand collaboration across disciplines and borders to protect populations and share medical innovations.  This collaboration model meets with scepticism on two sides: those who mistrust public health provision and those who mistrust the pharma industry. It’s not surprising, therefore, that vaccines meet with antagonistic campaigns and conspiracy theories from a coalition of unreason.

The body’s weapons

Vaccines are different from conventional medicines because they do not directly attack the disease: they provoke the body’s natural immune response against the disease, like a mock-invasion used as a military training exercise. A vaccine dose consists of dead or inactivated disease organisms, or biochemical agents derived from them. In designing a vaccine, scientists trade off risks and benefits.

The first vaccination was conducted by the rural English physician Edward Jenner in 1796. Hearing that local milkmaids who contracted a minor infection called cowpox never seemed to contract the deadly smallpox, he deliberately infected a farm lad with cowpox and then, when he had recovered, with smallpox. (Medical research ethics have improved somewhat since then.) The use of a live disease culture for immunisation is now called inoculation.

The first use of an artificial vaccine was conducted by Louis Pasteur in 1885, using a vaccine developed by his colleague Emile Roux by dessicating the spinal tissue of rabies-infected rabbits. Pasteur gave the vaccine to a boy who had been mauled by a rabid dog. He came to no harm.

Vaccines are still news, with global mobility and shifting demographics making the challenge of immunity more complex and urgent than before. In 2012, new vaccines were developed to treat meningitis, shingles, rotavirus (a cause of infant diarrhoea) and whooping cough. Vaccination against HPV, the cause of cervical cancer, is a new priority for health systems. The GAVI Alliance, dedicated to providing vaccination programmes for children in the developing world, has funding from the Bill & Melinda Gates Foundation and the support of many pharma companies.

A vaccine coalition

A leading company in the European vaccines field (and the only specialist firm) is Sanofi Pasteur MSD, a collaboration between two major pharma companies with a long history of investment in immunity. Sanofi Pasteur is founded on the work of the Pasteur Institute, while Merck’s Dr Maurice Hilleman developed vaccines for measles, mumps, hepatitis A and B, chickenpox, meningitis and pneumonia. The joint company protects half a billion European people against 20 major diseases.

Paul Hardiman, Communications Manager for Sanofi Pasteur MSD, told Pf about the company’s unique role in the European immunity landscape. There are three reasons for the collaboration, he explains: “It avoids a duplication of effort in the drive to develop new and innovative vaccines. It also allows a focus on the strengths and suitability of vaccines for different markets from both companies’ portfolios. This in turn gives flexibility and supports public health priorities.”

The two parent companies are both deeply involved in the global project of the GAVI Alliance. Both Sanofi Pasteur and MSD “use a policy of tiered pricing (linked to a country’s ability to pay) to enable access to vaccines in GAVI-eligible countries. This has included significantly reduced prices on vaccines against HPV and rotavirus and a pentavalent childhood vaccine against diphtheria, tetanus, pertussis, polio and Haemophilus influenzae type B.”

In the UK, Sanofi Pasteur MSD plays a major role in public health immunisation programmes for children, young adults and elderly people. These “are secured through competitive national tenders, requiring the consistent and timely supply of large volumes of high-quality vaccines”. The company has dedicated vaccine representatives selling directly to pharmacies and GP practices.

“Every year, the Joint Committee on Vaccination and Immunisation (JCVI) carries out a horizon scanning exercise to identify all potential new vaccines expected from manufacturers that may have an impact on public health over the following five years.”

As public health in the UK shifts to local authority provision, vaccine suppliers need to be fully aware of the economics and logistics of immunity. Sanofi Pasteur MSD’s UK sales force are “vaccine experts, engaging with practice nurses and GPs to support them in the areas of vaccine supply, campaign organisation and communication, and the education of vaccinating HCPs.”

The company is now supplying Gardasil for a schools-based vaccination programme to protect teenage girls against HPV and hence against cervical cancer. It is also preparing to supply Zostavax for a national programme, starting later this year, to immunise senior citizens against shingles. In the future, the company hopes to target, cancers, allergies, addictions and diseases of the central nervous system.

Immunisation programmes deliver savings both in the short term (by reducing the need for acute treatment) and in the long term (by reducing disability and chronic illness). As the focus of healthcare shifts further into the community, vaccines are increasingly crucial weapons in the HCP’s armoury. Their value, the company maintains, can be expressed in both health and economic terms.

Diplomatic immunity

In February 2013, nine female health workers responsible for delivering polio vaccination programmes in the Kano province of Kenya were murdered by gunmen after a local preacher condemned the vaccine as a plot to cause infertility. Similar killings have happened in Pakistan. In the US, ideologues opposed to public health programmes have accused the Obama government of spreading disease in order to experiment on the public with dangerous biological agents. The internet has given these conspiracy theorists a large audience.

In the UK, a spurious panic was created around the MMR vaccine by Andrew Wakefield’s article in The Lancet in 1998, which claimed the vaccine was a cause of autism. As the BMJ has recently reported, the article was scientifically discredited within a year, and has since been exposed as an “elaborate fraud” based on research that never took place. However, Wakefield’s claims are still declared to be accurate by the Daily Mail and its bizarre columnist Melanie Phillips.

Why do vaccines inspire so much mistrust? The reasons are complex. Some people believe that harnessing the body’s immune response is ‘interfering’ with nature. Others maintain that public health programmes violate the responsibility of the individual to determine their own healthcare. Still others claim that immunisation programmes are a form of covert surveillance, or even of biological warfare.

Paul Hardiman argues that vaccination may be a victim of its own success: “Anti-vaccine sentiment is thought to arise when people no longer fear the disease for which they are being encouraged to accept vaccination. As vaccine coverage increases, serious disease starts to disappear along with people’s fear of the disease. As people lose sight of the threat, so anti-vaccine sentiment may replace the good reasons for vaccinating – raising concerns in people’s minds.”

Doctor and writer Ben Goldacre, whose book Bad Science is strongly critical of anti-vaccine conspiracy theories, argues that the industry is not blameless: “I think it’s fair to say that anti-vaccine conspiracy theories are a kind of poetic response to the obvious regulatory failure in medicine and in the pharmaceutical industry. People know that there is something a little bit wrong here.”

For example, he notes, the recent murders in Nigeria took place in the same province where Pfizer had run the Trovan antibiotic trial in 1996 – a trial whose controversial nature led to Pfizer paying the Nigerian government £75 million to settle out of court, and inspired John le Carré’s novel The Constant Gardener.

Goldacre comments: “There’s something interesting happening when a very destructive anti-vaccine conspiracy theory built around fear and anxiety that drug companies are behaving badly arises in the same very small province in northern Nigeria where Pfizer have been running a trial which many regard as unethical.”

As Valentine’s Day nears, pharmaceutical sales professionals may feel tempted to blend work and romance. But is an office affair the sugar or the strychnine in your coffee?

We spend more time at work than awake in any other place. The office environment brings people into contact for 30 to 40 hours every week. That’s the equivalent of a long weekend, at least in clock terms. And the office clock is bigger than any clock you’ll see at home. As winter thaws into a bright and breezy spring, what could be more natural than a touch of office romance?

The vital statistics are persuasive. According to the recruitment website careerbuilder.com, four in ten workers have dated a colleague – and of those, three in ten ended up living with that person. And you thought having a shared Tupperware box in the company fridge was taking a chance.

The advantages of dating a colleague are obvious. In a busy life, it makes dates easy to arrange, it ensures that you spend plenty of time together. It also ensures that your lover understands your working life and that the two of you have some common interests and experience. And... no, that’s it.

The disadvantages – where do you start? It’s like taking two drugs that have contraindications a mile high. Love is a fatal distraction from work. Work is a fatal distraction from love. It’s near-impossible to be apart from someone you share an office with – great if they are your world, but (sorry to break this to you) life’s not always like that. A bust-up could break not only your heart but your career.

So are you willing to jeopardise your health, income and happiness? Are you willing to look like a fool, cry into your keyboard, and have your manager feel sorry for you? Are you willing to break the 11th commandment (Thou defo shalt not get frisky with a workmate)? Are you willing to confuse the professional and the personal against all rules of corporate conduct and private good sense?
As HR love to tell us, every challenge is an opportunity.

Tender proposals
Let’s examine a couple of case studies. Firstly, Mike and Claudia (names changed to protect the not so innocent) of Munchkin Pharma. These two talented young professionals worked in separate departments: Mike in sales, Claudia in marketing. That ensured regular contact but also lots of time apart, and soon their meetings developed a subtext. Within a few weeks, the subtext had become the text. When they accidentally on purpose met in the kitchen, the text was reduced to captions under pictures better not described. Then Mike fell out with his manager and left the company. Claudia moved in with him, and her enthusiasm for the job waned. Within a month, she had gone too.

Maxine says: 8 out of 10 for romance – I’m docking one point for the kitchen routine, and another point for being too cute. 2 out of 10 for professional conduct – that’s one point each for managing to remember where you worked.

Secondly, Liz and Aaron of Yellow Brick Road Pharma (company name changed to maintain professional confidentiality). These two experienced professionals were a couple before they worked together. Liz, a sales manager at YBR, wangled a freelance web design role for Aaron. All went well until Aaron and a female sales colleague (who shall remain nameless) developed an especially close working relationship. After reading a text from Nameless on Aaron’s iPhone, Liz announced a ‘clear desk policy’ in the office and handed the two miscreants the fragments of their shattered desktop computers in matching bin liners.
Maxine says: nothing.

Code of misconduct
To live outside the law you must be honest. Or as my line manager usually puts it, we need some rules here. Based on frank dialogue with colleagues (during the staff Xmas party), and on bitter experience (following said party), here are Maxine’s 10 tips for a successful, sustainable and survivable office romance.

1. Don’t date the boss. Not ever. If you do, you’re finished both personally and professionally. And that includes flirting. Don’t engage in idle conversation about how James Spader and Maggie Gyllenhaal are your favourite screen actors, then innocently remark “Oh yes, and they made a film together...” Don’t leave a well-thumbed copy of 50 Shades of Grey on your manager’s desk with your name, mobile number and MSN account details in it.

2. Don’t go too fast. Romance is not a time and motion study, and you’re not being assessed on productivity. Resist the temptation to place your dates on the department’s schedule. Don’t suggest meetings to set targets for the partnership and draw up a list of action points.

3. Keep it outside the office. No touching, no ‘quiet word’ chats, no typing ‘I love you’ in Morse code on your secret other’s computer. Romance and work are mutually hostile programs: don’t mix them on your system. However, that doesn’t mean you should maintain poker-faced indifference towards your SO in the workplace. A smile, a discreet “Hi” and a readiness to pick up signals (if your lover gouges your name out of the staff list in the signing-in book, that’s often a bad sign) can go a long way.

4. Don’t let booze drive the agenda. If you only want your SO when you’re drunk, it’s the bottle you’re dating. If that’s the way you want it, fine – but don’t fool yourself it’s a romance. The office gives you an opportunity to assess your feelings towards your SO while sober. If the result makes you want to drink, go and drink alone.

5. Maintain a solo working routine. Don’t engineer situations where you and your SO work together. Few intimate relationships and fewer jobs flourish on those terms. Don’t let your romance drive your working day. If all you can think about is when you will next see your SO and exchange meaningful glances, get a life.

6. Don’t let technology be your cupid. Sending private e-mails or Skype messages under cover of work is a major waste of your time and attention. Imagine making the same effort to contact a meercat on Mars – that’s how stupid it is. (And if that thought turns you on, you are ill.) Besides, technology sets the wrong tone: romance is about male and female (or female and female, or male and male), not e-mail and voicemail.

7. Let technology be your cupid. Romance, like sales, calls for good timing. In your own time, use the magic of telecommunications to source romantic items and services and to set up the perfect delivery. From overnight trips to picnic hampers (see page 22 for some ideas), from flowers to Byronic poetry, Google will put arrows in your bow.

8. Keep your dignity. Nowhere in the office is soundproof. Not for a ‘quiet word’, certainly not for an argument, and absolutely not for intimacy. Sex on a desk isn’t naughty, it’s just sad. And uncomfortable.

9. Have an exit strategy other than resigning. If the romance ends, make sure neither of you is harmed professionally. Resist any temptation to make working life difficult for your ex-SO: that will lose you the sympathy of your colleagues. Like a working relationship, an affair has to be wound up in a way that leaves both parties ready to accept the past and move on. Alternatively, there’s violence.

10. There are no short cuts. Don’t treat your romance like a service contract. Don’t use NLP in the bedroom. Above all, don’t regard patience as a ‘nice-to-have’ that you can sacrifice to the god of efficiency. Hasty, distracted and routine liaisons corrupt your heart with the ethos of the office – the worst crime of all.

APODI’S Jan Cox examines the importance of focusing on individuals’ strengths and talents when recruiting.

Over the past decade, Gallup has surveyed more than 10 million people worldwide on the topic of employee engagement, and only one-third “strongly agree” with the following statement: “At work, I have the opportunity to do what I do best every day.” A natural conclusion is that in an average organisation, approximately two-thirds of employees do not believe they are maximising the talents they have.

The repercussions of such a massive waste of talent – for the economy, for individual organisations, and to the quality of life of every one of those employees – is mind blowing. When attempting to explain to our clients the impact that such a scenario has on performance, we suggest that they explore this by changing the roles of a small number of employees to maximise their talents. The results are usually dramatic. We then ask the organisation to consider these outcomes if they were to be extrapolated across the whole company.

Implications for recruitment

The implications of such findings for recruitment, development and promotion strategies are significant. At Apodi, we have built a recruitment model that incorporates four key attributes that we test when recruiting every individual. These are: strengths/talent, competencies, cultural fit and mental toughness. Most companies traditionally recruit on competencies (i.e. what people can do) rather than on strengths/talent (what they are really good at, have a passion for and are usually inherent within an individual). The problem with recruiting based solely on competencies is that organisations risk hiring people that can do something, but may have no real inclination to do it. They may lack passion or excitement, display little energy for their work and therefore underperform. This results in disengaged employees who are unlikely to stay with a company for long.

Conversely, those companies that have adopted a strengths/talent-based approach to recruiting are showing dramatic results. Banks in the US are seeing significant increases in sales revenue from representatives recruited based on strengths. Financial services companies in the UK are reporting ‘improvements in quality and lower staff turnover’, and Starbucks have established a clear link between recruiting for strengths/talent and customer satisfaction.

The benefits can be summarised as follows:

Talent , competencies and strengths

The link between talent, competencies and strengths is simple: talent + competencies (knowledge/skill) = strengths. Talent can be defined as those capabilities that individuals naturally exhibit based on experiences and knowledge usually gained in early life, or those that an individual seems to be ‘born with’.

Talent can obviously be displayed in diverse circumstances, however, wherever it is utilised, it gives individuals energy and enthusiasm. Knowledge and skills are those things that are learned, studied and practiced. When combined with innate talent, skills and knowledge can be converted into real strengths. It is these strengths which drive performance. It is because of this causal link that leading recruitment organisations recommend that clients assess talent and competencies separately and as part of a strength-based assessment process.

How to assess for strengths

A strengths-based selection process has many similarities with that used for assessing for competencies. There are, however, some fundamental aspects which must clearly focus on the strengths of an individual. Assessing for strengths can be summarised as follows:

a) Strength-based role profile

A company can develop the profile by reviewing organisational structure and business strategy, developing performance criteria for the role in question, and studying the best performers in the role to identify the strengths that are contributing to success.

To help identify and define the strengths it is seeking, organisations can turn to experts in this field for guidance. For example, Tom Rath in his book Strength Finder identifies 34 particular strengths that may be important in different roles in commercial organisations. For instance, a company looking to recruit sales representatives may identify the following strengths as being the key to success in the role:

• Achiever/results focus – real focus on results, targets,completing tasks, meeting deadlines
• Empathy – identifying with customers and seeing what is important from their perspective
• Resilience –dealing with rejection and setbacks easily and moving forward positively
• Self confidence – strong self belief in own abilities
• Initiative – working independently and taking important decisions quickly to make things happen
• Communication – bringing propositions to life through effective communication.

b) Strength-based profiling tool

An appropriate profiling tool should be used to assess the key strengths of each individual applicant and how well they fit the selection criteria. The report generated can then be used as part of the strength-based interview.

c) Strength-based interviews and assessment centres

Fundamentally, interviews and assessment centres need to be focused on how individuals have previously
used their strengths to achieve success in their business and personal lives. In addition, they should also explore whether:

• The aspirations each individual has for the future
  are consistent with the strengths they display
• The individual will be able to apply the strengths
  they have to the specific challenges the company
  faces and the challenges of the role.

d) Review and measurement process

Recruitment decisions are among the most important that management can make and yet recruitment is one of the most ‘under’ managed processes in corporate life. It is rarely subject to stringent review and measurement, and consequently many ineffective and unsuccessful recruitment processes remain in place. Those more enlightened companies considering strength-based recruitment should ensure that new processes are reviewed and measured systematically and regularly. This will drive a system of continuous improvement and encourage buy-in from senior management and the organisation as a whole.

Conclusion

A reliance on purely competency-based processes for recruitment decisions is almost certain to ensure suboptimal recruitment decisions and, ultimately, sub-optimal performance. However, world-class recruitment processes are a strategic imperative for a company’s future success. Not only has the strengths/talent model been shown to add value to recruitment decisions, it can be a catalyst for performance improvement across any organisation.

Selling medicines in today’s marketplace should be built on partnership principles. ABPI CEO Stephen Whitehead talks exclusively to Pharmaceutical Field about the importance of NHS/industry partnerships.

Back in 2009, Chris Brinsmead – then President of the ABPI – told Pharmaceutical Field that the future role of the pharma field force would be to facilitate partnerships between the NHS and industry. Three years later and the partnership agenda is slowly inching forward. Progress has been made, but adoption of a more collaborative approach across the country has been variable. As ever, there are early adopters, and those that wait. Last month, Pf led with an ABPI announcement that predicted the NHS and industry would ‘become partners within 3-5 years’. Why not now, came the familiar cry? Why not, indeed. The ABPI seems determined to address this.

This month, Pf spoke exclusively to Stephen Whitehead as he approached the first anniversary of his tenure as CEO at the ABPI. It is clear that, in challenging times for the UK industry as it battles to ensure that patients gain access to life-changing medical innovations, partnership sits at the heart of the ABPI agenda.

“There is a currently a big commitment to move the joint working agenda forward,” says Stephen. “Strategically, over the past 15 years there has been the emergence of many different influences on prescribing – NICE, local commissioning and local formularies are obvious examples. The industry now has to work with a wide variety of stakeholders to demonstrate the value of its medicines. And traditional sales representatives have to work with many different and more complex audiences than they used to when they were purely detailing. Increasingly, I think joint working is the vehicle best suited to satisfy these varying demands.”

Innovation Health and Wealth
The environment for a more collaborative approach is certainly improving. The Innovation Health and Wealth review last December reiterated the need for greater partnership working to help accelerate the adoption and diffusion of innovation in the UK. Crucially, it said that the NHS needed to be ‘open for business’ on partnership. As such, advocates from both parties are working hard to raise the profile (and the benefits) of the approach. But resistance and misunderstandings around joint working remain.

“One of the problems is that there are variable definitions and understandings of what joint working is,” says Stephen. “In simple terms, joint working is a partnership approach focused on solving a patient-driven issue. The industry has disease expertise, it knows how to manage conditions and has developed medicines in those areas. Joint working is about bringing that expertise together with the providers and focusing on patient outcomes. And often we can find cost savings in delivering those outcomes as well.”

Importantly, says Stephen, joint working is not sponsorship. “This is not about industry paying for something. Historically we have funded a lot of things and sometimes there is a real benefit to us bringing money to the table. But this is about changing that perception. Partnership is where two parties, with different strengths and weaknesses, come together to focus on a shared goal. In this case, that has to be patient care.

“The fundamental issue is about recognising the value of innovation and its implications for a pathway of care. By working together to find out how these medicines can be used appropriately, we can save money in the system, we can prevent unnecessary and costly hospitalisation and we can improve patient care.”

Medicines in the middle
In recent years, discussion has focused on whether UK pharma companies should reconsider their product-centric approach to customer engagement, and concentrate instead on developing services with the NHS. The caveat being that a specific medicine would form the core part of any service. But joint working is not an exact science. There is no one-size-fits-all solution – it’s simply about working together to establish the most appropriate approach in a given disease area. “It’s about products and services,” says Stephen. “Some of our members do offer services. But the way I look at joint working is that there is always a medicine in the middle of it – because that’s what we discover, develop and sell. In today’s environment, the only way that the value of that medicine can be truly realised is through joint working that reengineers the pathway of care.”

At present, most joint working initiatives are being built around new innovations – and are being used to redesign services and improve the care pathway. A good example of this is in the field of anticoagulants, where a number of new brands are coming to market. “The new class of drugs have gone through NICE have been recommended and should therefore be utilised,” says Stephen. “Old warfarin clinics should now be closing as patients move onto the new drugs. But to achieve that, and to free up the funds to be able to use the new innovations, we need to take other measures. And you can only do that, in my view, through joint working.

“It is my passionate belief that in most cases, innovative medicines will save money in the system – in the short, medium and long term. We simply need to work together to deliver it.”

Implications for pharma sales
The implications for pharmaceutical sales professionals are significant. While joint working is not always appropriate – aspects such as disease area or where a particular product is along its lifecycle are key factors in whether the approach is applicable – adopting a partnership approach most certainly is. “Joint working is a natural evolution of partnership principles,” says Stephen. “Industry engagement has changed from being a simple seller/buyer transaction, into seeking to work in partnership with customers to ensure the NHS properly maximises the value of medicines. The UK has a low price and a slow uptake of medicine – and as a consequence, the UK system is not as efficient as it could be. It would be more efficient if it adopted innovation more quickly. And if it did, we would certainly have better patient outcomes.

“Joint working is best used when you want to coax the system into innovation. It is not always the most appropriate approach. But whatever you have in your medicine chest, partnership is always applicable. In today’s marketplace, how you approach selling that medicine should always be built upon partnership principles.”

The Health & Social Care Bill has finally completed its arduous passage through parliament. In normal circumstances, the landmark of Royal Assent would provide a key moment of clarity for the future of the healthcare in the UK. But this is the NHS – and nothing is ever that simple. Whichever way you look, the health service is bedevilled by variability. NHS Alliance CEO Mike Sobanja and Cegedim Relationship Management’s David Round look at the implications of the Bill for industry in the next 12 months.

The Health & Social Care Bill has, as we all suspected it would, survived the onslaught and made the statute book. But the hard work really does start here. In truth, implementation of the reforms on the ground began many months ago – but the process will continue for some years to come. It is a time of great uncertainty for NHS and industry alike. We now have official confirmation of where we are heading, but do we really know how we are going to get there? And with health need omnipresent, what should we be doing to protect the needs of patients today as we journey towards the health system of tomorrow? The wider call is for more collaborative working between the industry and the NHS. And there is much that the industry can do to support the significant challenges its customers face.

So where are we now? And what do pharmaceutical companies, facing an NHS in flux and customer groups in transition, need to do to support the health service and drive improvements in care? At a time of uncertainty, the industry must first do two things: follow the law, and follow the money.

Following the law and the money
At the moment – in law – we still have the presence of 151 Primary Care Trusts (PCTs). These are, of course, clustering together, while alongside them a high number of Clinical Commissioning Groups (CCGs) are steadily being established. For now, however, PCTs remain legally responsible for the delivery of healthcare services in the UK – and will continue to do so until April 2013. PCTs are currently accountable for about 80% of a total NHS budget of roughly £110 billion. It is estimated that approximately £30 billion of this has already been delegated to around 250 CCGs. But whilst PCTs can legitimately delegate their powers, they cannot delegate accountability. If someone in a shadow CCG busts the budget or, worse still, a patient dies by virtue of a poor decision elsewhere – the ultimate responsibility still lies with the PCT.

The situation on the ground is therefore complicated. Power currently rests with a number of PCT clusters acting on behalf of still legal and existing PCTs, who are delegating cash and power on the ground to CCGs. In turn, the CCGs are enjoying increasing control over finances, though technically, they are not yet legally in existence.

So if the task for 2012 is to follow the law and follow the money, pharma must focus on developing its powers of local intelligence. The fundamentals are simple, but the devil is in the detail. The law tells us who is technically responsible, the money tells us who has been delegated the power and the pound. The £30 billion question for pharma, however, is: where has the money been delegated? And the answer, of course, varies from locality to locality.

Developing the knowledge: think local, and national
And so the industry is playing a new game called ‘Spot the Commissioner’. To compete, pharmaceutical companies – and in particular their field-based professionals – need to build and maintain knowledge of local circumstances that, to a large extent, they’ve not previously had.

The move towards a localised health service is a direction of travel rather than an absolute. Moving forward, the industry perhaps needs to view the NHS as a healthcare system that operates within a national framework, but with more local decision-making. The balance of power between local and national is dependent upon which aspect of the healthcare service, and which therapeutic area, is being discussed. NICE provides a good example. In theory, the statutes require that funding is made available for technology appraisals as formal TAGs within three months of NICE making a declaration. But the reality is that whereas NICE doesn’t have to consider affordability, local decision-makers do – and therefore exactly how they implement that will inform their local decision.

As such, pharmaceutical sales professionals need to keep one eye on the national scene and one eye on the local scene – and apply that knowledge to their individual therapeutic area. They need to think very hard about how any national decisions will affect their product at a local territory level. The promotion of pharmaceuticals has moved beyond the traditional sequential sale – it is now much more sophisticated. This sophistication is only likely to increase in the future. An example of this will be the introduction of Health and Wellbeing Boards. These are already establishing under the umbrella of local authorities and will bring together interests from a wide variety of other groups: employers, magistrates, courts, local authorities etc. These will have a significant influence on local health services.

Variability: process, progress and prescribing
In such a changing and dynamic customer marketplace, the challenge of playing Spot the Commissioner becomes ever more difficult. Ironically, the only one constant is the prevalence of variability. There is variability right across the system, particularly in terms of progress around the health reforms. For example, there are local areas adjacent to one another where one locality has seen significant lawful delegation of powers to CCGs, while its neighbours have seen very little. This variability is likely to continue for some time – beyond the point where CCGs are authorised as official legal bodies. Authorisation itself is not a simple ‘yes’ or ‘no’ – it may be conditional. A conditional authorisation may mean that a CCG has power to make decisions over some things, but not others. A CCG may, for example, be authorised to commission acute services locally, but not mental health services.

At a wider level, variability in local progress with NHS reforms is surpassed by the even more significant issue of variability in care across the UK. The introduction of the Atlas of Variation in November 2010 has brought the issue into much sharper national focus and highlighted areas where progress can be made. There is, of course, variability in every disease area. Here are two very different examples. For patients with type II diabetes, the likelihood of suffering a lower leg amputation as a result of the disease is greater in the South West of England than it is in the South East. On the other hand, around the issue of cancer referral times, there is huge variation across the country in terms of GPs referring patients to secondary care for earlier diagnosis. The latter is an example of variability in health care – the former is a great illustration of variability in health outcomes.

Addressing inappropriate variability is a key priority for the NHS. And it is an area where the pharmaceutical industry can help make a real difference. Pharma companies could start by looking at the variability in the prescribing of their own products. If they can identify where that variability is and draw it to the attention of the health service locally, they will be better placed to offer support to help address it. The industry could consider undertaking Health Equity Audits to generate disease-specific data to support commissioning. For example, if you are a sales professional, what could you tell a customer about how your therapy is used in terms of its distribution among social classes, poor or rich and ethnic groups? What can you say about its relative prescribing across geographical areas? This is key information. It’s likely that there will be all kinds of variability going on that the industry could be helping the NHS address – and in doing so, it will also drive the market. By combining publicly-available prescribing data with activity data and other readily-available metrics, companies can improve their sales and marketing strategies by providing customers with the best information to help inform commissioning decisions.

The value of data
Robust data and information is the lifeblood of good commissioning, and good commissioning is the lifeblood of good health outcomes. At present, few, if any, commissioners will have complete and comprehensive access to the right data on which they can base critical commissioning decisions. But, in a collaborative environment, many would be willing to work with the industry to help create that evidence-base. As the NHS restructure unfolds, pharma can be a credible source of information for commissioners – though probably only one of a number of sources. Increasingly the health service will seek to identify data itself, and the Atlas of Variation is a good example of that. Increasingly, there are good examples of joint working where parties have come together and delivered results. In a collaborative era, wracked by challenge and change, the industry and the NHS have a responsibility to develop that relationship further.

Pharma can certainly emerge as a valuable partner to the NHS as it moves through its transition. But the generation and communication of robust and relevant data will be key to progress. In the game of Spot the Commissioner, the best sales professionals will be those who understand the local situation, understand what is driving it and align their key messages so that they are seen as part of the solution, not part of the problem. Undoubtedly, access to good data will underpin everything.

Mike Sobanja is CEO, NHS Alliance. David Round is General Manager, Cegedim Relationship Management.