Andrew Lansley has insisted he and his successors as Health Secretary will have a duty to provide a comprehensive health service via the NHS Commissioning Board and CCGs.

The Secretary of State for Health has said it will remain incumbent for those in the position to ensure services currently provided by the NHS.

Speaking at the National Association of Primary Care conference, Mr Lansley said “that is in law, in essence, what is described as a comprehensive health service.”

Changes to the duty of the Secretary of State to provide a comprehensive health service have been one of the most controversial aspects of the Health Bill since its release and its debate in the House of Commons and the House of Lords.

“It’s the duty that has been placed on me and my predecessors for more than 60 years and it will be incumbent on you to discharge that duty in the future - and it will remain incumbent on me and my successors to ensure that through the NHS Commissioning Board and through your CCGs that service is provided,” Mr Lansley told delegates.

The Health Secretary also emphasised the freedoms CCGs would have under the NHS reforms. But he outlined the opportunity would only come with the responsibility to ensure patients have “access to the NHS services” they require.

“You will have the freedom to choose who should support you in taking charge of local health services,” he said. “Clinical senates and clinical networks will be there to advise you, not to tell you what to do.

“You will have the freedom to structure yourselves to meet the needs of your population, providing you involve members of the public, with nursing and secondary care experience on board.”

The NHS is not using high-value diagnostic imaging and radiotherapy equipment to its full capacity and is failing to meet patient needs as a result, according to a report from the Government’s Public Accounts Committee.

The report, ‘Managing high value equipment in the NHS in England’, stated that poor co-operation between trusts is leading to a “scandalous” shortfall in provision of vital services such as post-stroke scans.

NHS Supply Chain has said it is working with the DH to address the issues raised by the report and the “significant challenge” of procuring costly but much-needed equipment.

The NHS in England spends approximately £50m per year on MRI and CT scanners and linear accelerators for radiotherapy. However, the Committee said, the use of this equipment to provide services is “fragmented and uncoordinated”.

The number of CT scans carried out per machine in a year was found to vary between 7,800 and 22,000, with availability ranging from 40–100 hours per week.

Shockingly, the report found that only 50% of stroke patients received a CT scan within 24 hours – an essential service for determining immediate treatment.

Margaret Hodge, Chair of the Committee, said the way high-value equipment is bought and used by the NHS “is not providing value for money”. She described the shortfall in post-stroke CT scans as “scandalous” and the inequalities in usage between regions as “unacceptable”.

“The Department of Health has got to look at how machines can be used more efficiently to make the best use of scarce resources,” she concluded.

The report highlights the challenge for the new NHS Commissioning Board to ensure that Foundation Trusts work together to ensure access to capital equipment.

Health Minister Simon Burns commented that more streamlined procurement of scanners had already begun: “The NHS has saved up to 15% on scanners by working with NHS Supply Chain to co-ordinate large orders over time with other trusts. This is the NHS working smarter.”

“We are currently working with the Department of Health to consider the recommendations in the report,” said Andy Brown, NHS Supply Chain’s Managing Director for Diagnostics. “Buying and maintaining equipment during times of budgetary restraint will provide a significant challenge for NHS trusts and our range of frameworks to plan, aggregate, purchase or lease and maintain high-end equipment will be invaluable to the NHS.”

A new childcare product designed to improve posture and assist spinal development has been launched by a UK company.

The PosturePadJunior wedge cushion (pictured) from Derby-based Jolly Back Enterprises was developed with support from the Healthcare and Bioscience iNet, which is part-financed by the European Regional Development Fund (ERDF).

Designed by physiotherapist Lorna Taylor, the product was launched during National Back Care Awareness Week.

Taylor received an iNet Innovation, Advice and Guidance grant, which enabled her to design and test the wedge cushion prior to commercialisation. She is working on a DVD to train teachers and nursery managers in manual handling and back care.

The same company launched the Jolly Back chair earlier this year, using the same wedge-shaped cushion technology to prevent or reduce back pain. The product has 23 UK distributors and has sold worldwide.

“As a children’s physio, I am concerned at how child development is being adversely affected by current lifestyles,” said Taylor, who noted that correct positioning of babies can “allow core strengthening of the back and neck”.

Taylor described the PosturePadJunior wedge cushion as “a simple means of naturally supporting the spine for comfort and physical development”.

iNet advisor Dr Ros Graves commented: “Lorna has shown incredible resourcefulness by coming up with simple but effective products and bringing them to market so efficiently. The potential impact of all her ideas is enormous so we are delighted to have been able to help.”

The Healthcare and Bioscience iNet is an initiative delivered by Medilink East Midlands that assists companies and inventors in the healthcare sector to develop new technologies, products and services. It brings together firms, academics and public service representatives.

The idea that ‘any qualified provider’ can deliver NHS services may be contentious, but it has roots in existing policy. Thoreya Swage examines the opportunities for industry in the changing health provider landscape.

Successive governments have tried in recent years to shake up the healthcare system in the UK, with England probably being subject to the greatest number of changes. A key element of these shake-ups has been various attempts to expand the healthcare market in order to include the private or independent sector.

This widening of the doorway started in earnest with the deployment of the waiting list initiative in the 1990s, using the spare capacity of independent hospitals to reduce the queues for elective procedures that had built up in the NHS.

The baton was then taken up by the independent sector treatment programme under the last administration: the range of work done by private providers expanded to diagnostic procedures and screening programmes, as well as the construction of bespoke independent hospitals to take on hip, knee and cataract operations from the NHS.

It was at this stage that the concept of patients choosing which healthcare institution to go to for treatment or diagnostic procedures started to take off, with some of those options being in the independent sector. The idea of an ‘any willing provider’ began to take shape, with NHS care being delivered by any appropriate healthcare body as long as it had reached identified quality and safety standards.

However, before the recent change of government this initiative began to cool under external political pressure and at one time even seemed likely to fade away.

What AQP means

Despite opposition, the coalition Government has renewed the ‘any willing provider’ policy, calling it this time ‘any qualified provider’. In July of this year the Department of Health in England issued ‘operational guidance’ to the NHS providing further details to PCT clusters and the emerging Clinical Commissioning Groups (CCGs) – the renamed, modified GP consortia.

This policy has come under the guise of improving the quality of care by widening patient choice for specific services.

The intention is to permit the patient to choose from a list of qualified providers when they require a referral for a specific community or mental health service. To meet the ‘any qualified provider’ (AQP) requirement, a healthcare organisation needs to fulfil the quality, price and contractual obligations for NHS services. This process, as we have seen, is already in place for elective care.

The guidance states that the implementation of AQP will be conducted in phases from April next year. However, some work needs to be done before that. PCT clusters and their associated CCGs need to have decided which community or mental health services they wish to identify for the implementation of AQP locally by October, so that their patients can begin to have access to that care between April and September next year. Three or more services from the following list, drawn up by the DH in conjunction with patient groups, should be identified:

• musculo-skeletal services (neck and back pain)
• audiology services in the community (adults)
• continence care (adults and children)
• diagnostic services (e.g. imaging and heart and lung investigations)
• wheelchair services (children)
• podiatry services
• wound healing and management of leg ulcers
• primary care psychological therapies (adults).

The guidance also says that PCT clusters and CCGs can choose alternative services for AQP in different priority areas if these are supported by local patients – for example, as identified through the shadow health and wellbeing boards (the new joint health and social care joint commissioning boards) – and effective gains in quality and access can be made by doing so.

Getting involved

How can independent provider organisations participate in this process? The principles of the AQP approach are as follows:

• Organisations can qualify and register to provide NHS services as long as they meet NHS assurance requirements.
• Referral pathways and protocols set by CCGs must be accepted by the providers wishing to be on the AQP list.
• Patients are offered a choice of services from the list of qualified providers.
• There will be a fixed price based on a national or local tariff, to ensure that the provider is chosen by quality.

A national qualification process for all AQP providers is currently being developed by the DH in order to minimise bureaucracy and reduce transaction costs. The proposed principles for qualification are that providers:

• must be registered with the Care Quality Commission to demonstrate that they meet the essential standards for quality and safety (or equivalent assurance requirements if providing services not covered by CQC registration)
• are licensed by Monitor (from 2013) so that they are authorised to deliver NHS care
• can meet the terms and conditions of the NHS Standard Contract, including having regard for the NHS Constitution, appropriate guidance and legal obligations
• deliver care at NHS prices
• can meet the service specifications developed by commissioners and comply with referral protocols
• agree with the commissioners on any supporting schedules to the NHS Standard Contract, e.g. on activity levels.

More details of the qualification process will be published this autumn.

The providers that have successfully achieved the national qualification process will be listed in a directory available to GPs later this year.

By November 2011, lead PCT clusters will have produced detailed implementation packs for each service on the AQP list that will include service specifications, contract currencies, tariffs and information models.

It is anticipated that AQP for the services identified above will begin to be implemented from April 2012, with all CCGs having this in place for their patients by September 2012.

What happens next?

AQP will continue to expand: for 2013/14 a further list of services has been identified by the DH for discussion with commissioners, patient groups and providers. The list is not finalised, but will probably include:

• maternity care, e.g. antenatal education and support for breastfeeding
• speech and language therapy
• supporting patients to self-manage long-term conditions
• chemotherapy in the community setting and at home
• primary care psychological therapies for children and adolescents
• wheelchair services (adults).

Opportunities for medtech

The most obvious opportunity for medtech in relation to AQP is in the sphere of direct access diagnostic services, where many investigations such as non-obstetric ultrasound, echocardiography, cardiac physiology, MRI, X-ray, endoscopy and phlebotomy can be provided in the community setting, as indeed some already are (e.g. via Inhealth). These direct referrals can enable GPs to obtain rapid investigations and help to manage their patients in primary care, without having to refer to a hospital consultant.

Another key area is adult hearing services, including audiology and hearing aid fitting. Telehealth and telecare also have a part to play in supporting some of these services by monitoring people with long-term conditions at home. The services identified for the initial phase of AQP have traditionally had poor information systems. Better data collection on activity and health outcomes will be vital for the success of the providers delivering services under this initiative.

The key challenge for medtech companies is to get onto the recognised list of AQP that the DH is drawing up, or to work with partners who will be applying to go onto the list. Rather than regarding independent providers simply as customers, medtech suppliers can work with them to achieve AQP success.

Potential providers need to get up to speed on a number of areas, such as ensuring that they are registered with the CQC, have a good understanding of the standard NHS contract, offer services in keeping with the CCGs’ requirements and can manage within NHS financial envelopes.

The aim should be to identify the lead commissioner(s) within the local PCT cluster and associated CCGs and find out which community services they are planning to include on their local AQP. Alternatively, contacting the local shadow health and wellbeing board (if it is sufficiently developed) may indicate other priority areas for AQP. This is an opportunity for marketing medtech services that can be shown to improve patient care and are aligned with the local health economy’s priorities.

Medtech providers should also be clear about whether they can meet (or help their partner organisations meet) the qualification requirements for AQP. They should look closely at the details of these when they are published by the DH later this year.

Companies should also start doing their homework now on pricing and the care outcomes that can be achieved through their services, bearing in mind that the NHS commissioners will be looking at how the five high-level domains of the NHS Outcomes Framework will be achieved.

Another key milestone to look out for is the implementation packs due in November on service specifications, contract currencies, tariffs and information models. These will require close examination by potential providers seeking to ensure that they are fully prepared for AQP.

Although this initiative seems small in scale it looks set to grow in the future, and further opportunities will present themselves for 2013 and beyond as AQP continues to expand. For more information, visit the Department of Health website.

Dr Thoreya Swage was formerly an NHS clinician and a senior manager in various NHS organisations covering acute and primary care. She has expertise in commissioning health services and is currently working for a number of NHS organisations, including DH agencies, to develop a more commercial approach to the commissioning of healthcare.

The NHS Alliance and the National Association of Primary Care (NAPC) have joined forces to create an independent body representing Clinical Commissioning Groups (CCGs).

The coalition will be the collective voice for practising clinicians, CCGs and their leaders to ensure that commissioning bodies are fully involved with the new NHS.

Dr Johnny Marshall, Chairman of NAPC, said: “We are seeing many obstacles, from all quarters of the NHS and elsewhere, being placed to deter and restrain the successful engagement and operation of CCGs.”

Dr Michael Dixon, Chairman of the NHS Alliance, commented: “We will listen to and represent CCGs’ views and concerns without compromise, wherever and whenever necessary. We will be a united voice that will serve to balance the top heavy approach often seen in the NHS.

“As the two organisations that have wholeheartedly championed clinical commissioning over the last two decades, we have a long history of commitment and dedication to the clinical commissioning cause.”

The coalition has agreed a number of shared principles. They include:

• NHS commissioning should be a public function exercised by statutory bodies in the public sector alone. NHS commissioners should be free to choose the support they need from whatever source they feel to be appropriate.
• The NHS should be based on an approach that maximises local responsibility and ownership through local determination rather than central direction, meaning that the NHS Commissioning Board should only take responsibility for things that must be done at national level.
• CCG Boards should have GPs as majority members with a strong primary care focus.  Boards will need to ensure the appropriate involvement of other clinicians and managers and have strong representation from local communities and independent directors.
• NHS provision should be appropriately distributed across the public, third and independent sectors according to the public interest. Those providing NHS services should clearly subscribe to NHS values of openness, transparency and accountability and behave in a manner consistent with those values.
• The NHS should develop integrated care, centred on the needs of the patient rather than the providing organisations, supported by appropriate payment systems.

The coalition has also established a number of priorities it sees as essential. They include:

• To lobby the Government to review the role of the NHS Commissioning Board to ensure that it is set up as an organisation that enables rather than controls CCGs’ work.
• CCGs’ self-determination – Clinical Senates, Clinical Networks, and Local Health and Wellbeing Boards should help not hinder CCGs, who must have the final decision with their patients. 
• Work with the Government to ensure that aspiring CCGs receive the funds intended to support their development.
• Oppose suggestions that CCGs should be constrained in their choice of commissioning support.
• Monitor and CQC to demonstrate that they are acting in the public interest. The coalition will seek to ensure that CCGs have the means of challenging their decisions.
• Transparency - the coalition believes that the payment of any quality premium to reward CCGs which commission effectively should be transparent, represent good value for money and be in the public interest. 

Both forces will contribute to and have ownership of the new initiative, whilst acting as individual identities regarding other functions.

Dr Johnny Marshall added: “Our respective organisations bring their particular strengths to the table to enable us to be bigger than the sum of our parts.

“The strength of our two organisations working in partnership on the same agenda should reassure Clinical Commissioning Groups of our commitment to their cause and that of their patients.

“We will strive to ensure that CCGs are not overburdened with NHS bureaucracy and red tape and are set free to deliver innovative and population focused services.”

A steering group is advancing the coalition's collaborative work.

The BMA has called for the revised Health and Social Care Bill to be withdrawn or substantially amended, arguing that its plans for competitive and market-led NHS reform still threaten the quality and integrity of services.

In a letter to all MPs, BMA Council Chairman Dr Hamish Meldrum has said that even in its current revised form, the Bill presents an “unacceptably high risk to the NHS, threatening its ability to operate effectively and equitably, now and in the future.”

The third reading of the Health and Social Care Bill in the House of Commons is due to take place on 6 and 7 September, after which the Bill will transfer to the House of Lords.

Dr Meldrum argued that the Bill places “an inappropriate and misguided reliance on ‘market forces’ to shape services”, with the “potential to destabilise local health economies” and, in the long term, to harm public health.

He also noted that, far from overcoming bureaucracy, the Bill is now creating a US-style legalistic environment of “excessive complexity and bureaucracy” to support competition between providers.

The BMA’s main concerns include:

• The Secretary of State is still not responsible for providing a comprehensive health service, only for ‘promoting’ one.
• The removal of the cap on Foundation Trusts’ income from private patients could lead them to focus their resources on private care.
• Forcing all NHS Trusts to become FTs could compromise patient safety and quality of care by placing a premium on financial targets.
• Promoting an increase in choice of providers appears to be a higher priority than tackling health inequalities and promoting integrated care.

“Meaningful, sustainable reform needs to have the full confidence of patients and those working in the health service,” Dr Meldrum concluded – and despite its apparent benefits to their professional interests, GPs remain predominantly opposed to the Government’s plan for the NHS.

Modern business now places a heavy reliance on the concept of outsourcing. Strategists across all sectors have recognised the potential for third-party organisations to manage key business functions, find efficiencies and drive growth. The pharmaceutical industry has been an active participant in the trend towards outsourcing services – not least in the key areas of sales and marketing. Pf’s Iain Bate looks at the global phenomenon of outsourcing.

The concept of outsourcing is not a modern ideology. The approach first came to prominence in the 1950s when specialist functions, such as advertising and legal services, were outsourced to third-parties by organisations large and small. From little acorns… In today’s business environment, as companies assess their core competencies, anything from research and development, manufacturing and marketing services to IT, Human Resourcing, accounting and supply chain activities are considered fair game to be outsourced.

Lift-off came during the 1990s, when rapid technological change and an increased sense of competitiveness saw companies take note of the flexibility, cost-saving potential and reduced risk in operations that contract organisations could offer. This quickly led to outsourcing services becoming widespread in developed economies.

The pharmaceutical industry has contributed heavily to the growth of outsourcing – in particular in the areas of Contract Research and Contract Sales. Contract Sales Organisations (CSOs) are now a major player within pharma. They manage a growing proportion of sales in the sector and, according to research by the Kalorama Information, the CSO market has been forecast to exceed $5bn by the end of the year. Of course it’s not just in pharma where CSOs have become popular, but without the pharma sector as a whole, it could be argued that the global market for contract sales would be nowhere near as significant as it is today.

Leading the way

It was largely the pharmaceutical industry which pioneered the use of CSOs and began outsourcing tactical sales effort. The provision of flexible and, in many cases, short-term resource to augment the efforts of the in-house sales force proved popular among many pharmaceutical companies. Since then a growth in the principle of outsourcing sales has seen CSOs develop their portfolios to offer a wide range of services beyond the tactical ‘share of voice’ model.

Beth Rogers, Principal Lecturer of Sales Management at Portsmouth University – and the former Chair of the UK National Sales Board and Research Director of the Institute of Sales and Marketing Management – says it was, and still is, this variety of services and the opportunity to trim costs which makes CSOs appealing.

But, certainly in a cold economy where finding efficiencies and delivering return on investment have become imperative, perhaps the biggest draw is flexibility.

“From my research, flexibility has been heavily emphasised by people I’ve been talking to who use CSOs – both providers and users,” says Beth. “It’s about effective sales resourcing as well as being efficient. Contract sales absorb some of the risk when you’re trying to be speedy to market with something which may have a relatively short life span. I think for pharma companies, it’s not so much that they’re gaining on operational costs, they’re certainly avoiding fixed costs, and that’s a factor.”

Modern day CSOs now get called upon for a variety of projects. Product launches are a common area in which they are used, but beyond this they are increasingly being asked to provide more specialist expertise for longer periods of time; clinical audits, nurse advisor programmes, Key Account Management, healthcare development and payer engagement are all areas where CSOs are being used to provide services. In some companies, contract resource is the only sales resource deployed. This represents a much more sophisticated use of contract sales than in many other sectors. “In some industries, CSOs are used for part of the sales process,” said Beth. “For example, it might make sense to have CSOs focused up to a certain point, until a degree of in-house expertise is needed to be applied. So you can get a hand-over from a contractor to a permanent employee once a lead has been developed.”

Past reputations

But despite the efficient and cost effective services CSOs are known to offer there still seems to be a reputation they have found difficult to shake off in some quarters. A study by Health Strategies Group in the US reported that contracted representatives had more difficulty accessing health professionals – doctors in particular. The study showed that in-house reps had more than a third (33%) more ‘sit-down’ visits than their contracted counterparts. But Beth believes that any former interpretations of CSOs that may still linger today are eroding, if they haven’t already.

“It may be a hangover from history – the kind of rent-a-rep image,” she added. “In fact, a lot of doctors are looking at e-detailing or telephone-detailing, so they’ve probably got a lot of choices on how they receive details. So, when they do want to see somebody personally, maybe they have got to a stage of knowledge where they want to see somebody with in-house expertise. I think CSOs are so widely accepted in the sector that there’s no real acute difference anymore. Ultimately there’s CSOs reps who have worked in pharma and vice-versa, so it’s probably a bit of a hangover from history which is on a downward trend.”

But not all companies have bought into the CSO model. Why is this? “I suppose it’s probably a cultural differentiation,” explains Beth. “Obviously some pharma companies have a very long history and perhaps were founded by philanthropists who had a paternal approach to staff and that remains today. That’s one possible reason. Another may be that a specialised firm with a particular medical specialisation might feel that, with the amount of training that staff would need, they would prefer to have them on a long-term contract.

“Beyond pharma, what tends to make the difference between high and low levels of outsourcing is to do with ‘cultural difference’. Differences in products/service and also sometimes variations in who in the customer organisation you are dealing with is, or whether you’re dealing with multiple people. Wherever selling has a high proportion of non-selling activity it could be a case of, ‘this could be a long sales cycle and it’s difficult to predict’, and therefore a permanent employment arrangement seems to have more advantages.”

The next generation

Yet there can be no mistake that the future is a bright one for CSOs. As the economy continues to bite and more business look to trim their wage bills, Beth believes that it won’t be just pharma that will come to rely on their flexible friends more often – especially with the potential, and promise in some cases – of new multiple models.

“I think for most sales managers in the sector it might be unpleasant. For many years there seemed to be a clear correlation between market share and feet on the street – particularly if you look at the past information from the US,” she said. “The reason that’s changing is partly because Government policy is creating some ups-and-downs in the market in terms of listing. There’s also general economic uncertainty, which means that shareholders are jumping up and down, and so, consequently, depending on history and specialisation, and decision makers that you’re working with, it’s probably more important than ever for sales managers to have choices and perhaps mix-and-match the way they use employed and contract staff.

“As it is there’s syndicated, dedicated, short-term and long-term contract models and that’s also happening in other industry sectors as well. I think we can trace the disintegration of the ‘feet-on-the-street’ equals market share model to about 2005/06. That was when it really started to look like we were going to have to do something differently. Now, five years later, the industry is testing out new models which are going to suit new circumstances. That’s where CSOs have an advantage being able to upscale and downscale quickly.”

CSOs are by no means an easy fix to problem solving. There is a risk and companies should study the history of outsourcing core and noncore function if they are to avoid making mistakes. But with convenient, flexible and adaptable teams of experienced staff able to transform performance it would seem CSOs look set to continue their close association with industries across the globe.