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.

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.”

A new quick-start reference guide to joint working to help address potential barriers to NHS/industry collaboration has been launched.

The ABPI guide maps the journey of identifying and establishing joint working projects, and offers guidance on how to implement, monitor and evaluate their success.

Stephen Whitehead, ABPI Chief Executive, said the guide aims to overcome “challenges whether you are an NHS or industry professional”.

The guide, Joint Working – A Quick Start Reference Guide for NHS and Pharmaceutical Industry Partners, was developed by combining materials published by the ABPI and the DH.

It was created in response to feedback from ABPI members and NHS partners to tackle typical challenges faced when developing joint working schemes.

The flowchart structure offers advice across the life cycle of a joint working project, from idea generation through to approval, recommendations and evaluation.

Mike Farrar, Chief Executive of the NHS Confederation, said the guide would be a “useful tool in helping build the foundations between the NHS and industry partners”.

Thousands of patients across the UK have already benefited from joint working between industry and the health service. The ABPI now hopes the guide will help stakeholders overcome any future obstacles that may prevent improvements in patient care as a result of joint working.

The switch to Key Account Management is one more companies are introducing to tackle current challenges. Apodi’s Tony Swift highlights the principles of effective execution and making a strategy work for a smooth transition.

More and more companies are now addressing the changing healthcare market by transitioning the sales process from one which primarily involves representatives engaging with healthcare practitioners on a ‘one-to-one’ basis, to the establishment of Key Account Management (KAM) teams.

The rationale for this change is irrefutable. Access to GPs is increasingly difficult and the ‘customer’ now represents a series of more complex accounts with numerous stakeholders and influencers. Furthermore, decision making is both at a national and regional level and there is now a greater need than ever to focus on local healthcare economy needs and requirements.

As a result, pharmaceutical companies have established, or are in the process of doing so, KAM teams in which individuals have increasing responsibility and autonomy in addressing the needs of their customers at a local level. Some pharmaceutical companies have even taken the model further and given team members, or a small collection of them in a specific locality, P&L responsibility – essentially establishing micro business units within the team itself.

 

A different approach

Some years ago it could have been argued that any company transitioning to the KAM model was differentiating itself from the competition. This argument is much more difficult today because most pharmaceutical companies have moved, or are moving this way – in short, almost everybody’s doing it.

However, there is still a key source of competitive advantage in this environment – and that is to actually make the new model succeed.

Our research, and the feedback we have received from companies trying to adopt the new model, is that the execution process is much more difficult than originally anticipated. The type of feedback we receive often includes the following observations:

• Account managers do not appear to be acting in any materially different way than the sales representatives of the past
• They are adopting the new model at vastly different rates with a small number leading the way and the rest struggling to come to terms with the new strategy
• The move to more local autonomy is creating confusion about the role of the centre and its interaction with the decentralised function.

 

Difficulty of execution

So why is it that so many companies are finding the execution process more difficult than anticipated? The primary reason is that there is often an underestimation of the scale of the organisational change required.

For instance, many sales functions in pharmaceutical companies have historically been based on a traditional command and control structure. Here, the sales management instructed sales representatives on which HCPs to target, how many times they should be called on and exactly what to say during any meeting with them.

Within the new model however, many of these individuals are now faced with adapting to a new environment where decentralisation, decision making, autonomy and P&L accountability are now among the order of the day. Given the above, managements’ task of transitioning the organisation from the old to the new model requires considerable skill, focus and expertise.

 

A decentralised approach

Many management commentators argue that decentralisation is a panacea for all ills. If executed effectively, in an appropriate environment, this structure can deliver enormous benefits to an organisation. However, the move towards decentralisation often creates a number of serious problems which, if not addressed directly and quickly, will significantly impact on performance.

These problems are as follows:

A lack of expertise: a decentralised structure almost always requires an increase in expertise in the key roles within the structure. For example, increased knowledge will be required by employees AND management to solve problems, address more complex customers and, in effect, run businesses – particularly if P&L account responsibility is part of the role.

Inertia: many employees enjoy going to work in an environment where they understand exactly what the day will bring; the common challenges they always face and, in exceptional circumstances, being able to refer any unusual problems to their line manager. In a new environment where their decision making authority is increased, many employees will be reluctant to do things differently and may continue behaving much as before.

Lack of responsibility: the new environment is a scary prospect for some people. The last thing they want is more responsibility and a fear of failure and an inability to work in the new way paralyses them – again leading to ineffective execution.

At Apodi we have looked at specific pharmaceutical companies that are struggling with the implementation of KAM teams and researched the reasons for their difficulties. In every single example, one or more of the problems outlined above was prevalent – and in most cases all three problems coexisted together.

In fact, some of our own executives have reported their own first-hand experiences of working with companies in which the almost evangelical zeal and enthusiasm of top management continued unabated whilst chaos reigned and they failed to achieve an effective transition.

 

The way forward

As we have seen, the execution process can be difficult. And because of this, it is critical that a clear procedure for managing an effective transition is implemented. This process needs to address the following:

1. Identify clearly the strategic intent of the company, including the projected benefits of changing the model and how these are to be measured

2. Given the strategy noted above, clearly identify the role of the centre and the role of the decentralised units and how these might evolve over time. In our view, companies are often too ambitious in managing the transfer of responsibilities from the centre to the divisions or KAMs. Clear standard operating procedures need to be driven from the centre in the early stages and KAMs need to understand the rules that they are expected to work to. Think carefully about giving newly formed KAM teams P&L account responsibility. It may be better to transition to this over time, and in some cases, not even to go this far

3. Identify very clearly the roles and responsibilities of management and KAMs at all stages in the change process

4. Given the roles identified in the new structure, carefully recruit the appropriate personnel. Implement a training and development programme focussed on areas such as the role of Key Account Management, the implementation of a complex sale, general business disciplines and other skills

5. Management need to quickly identify any KAM team member who cannot make the leap to the new world of working and deal with this appropriately

6. Instil best practices across the whole KAM team by establishing effective coordination and information sharing processes

7. Establish effective incentives to drive the performance required

8. Put in place appropriate controls, feedback, learning and corrective action processes to improve performance. Key to this is the management team that drives KAM performance. This team needs to be highly experienced and knowledgeable about the requirements of KAM teams and how to manage a change process.

 

Leading the way

As ever, the role of the leader is absolutely critical in driving through the changes to address the needs of the new healthcare economy. Whilst the development of a sound strategy is critical, it is also the relatively easy part of the process. In every pharma magazine, nearly all consultants and most competitors will support the notion of moving towards a KAM driven business.

However, it is the effective execution of this transition that the leader should focus on. They will also invariably experience many of the challenges that are common to such change programmes, such as internal politics, resistance to the new way of operating, lack of appropriate skills within the team and so forth.

It is because of this that a leader needs to draw on commonsense business disciplines to be successful. It is also crucial that the immediate management team are able to do the same. Therefore, before embarking on the process, it is important to make sure that the management team is capable and ready to execute change.

As I noted at the beginning of this article, many companies are implementing similar strategies. It is therefore logical to assume that, everything else being equal, it is the company that has the management capabilities to execute these changes most effectively that will gain a competitive advantage over its competitors.

 

Tony Swift is the Managing Director of Apodi. He may be reached on tony.swift@apodi.co.uk.

European medtech industry association Eucomed will launch a conference pre-vetting system in early 2012 to assess all third-party educational conferences and congresses sponsored by its members.

The new system is the first of its kind in the healthcare industry, because its assessments will be binding.

The independent Eucomed Compliance Panel will assess educational events for compliance with the association’s Code of Ethical Business Practice in relation to such factors as scientific content, location and venue.

Each outcome will be made publicly available via a dedicated website, and relevant stakeholders will be notified.

The Eucomed Code allows member companies to sponsor third-party educational events such as medical congresses, seminars and training courses, subject to restrictions. Until now, members had to establish their compliance independently. The new system will apply a uniform compliance determination process to all Eucomed members.

“The conference pre-vetting system is a unique initiative in the healthcare sector,” said John McLoughlin, Chairman of the Compliance Panel. “It will be supervised solely by our Panel, which is a completely independent body. Eucomed members are required to follow the assessments.

“If a conference receives a negative assessment, Eucomed members may not sponsor either the conference or individual healthcare professionals who wish to attend the conference.”

John Wilkinson, Eucomed’s Chief Executive, added that the new system “is not only necessary for our members in their day-to-day activities but is also key to increasing the consistency and transparency of industry behaviour.”

Eucomed intends to give key stakeholders an opportunity to comment on the assessment criteria.

The pre-vetting system will begin as a pilot and be reviewed 6–12 months after its launch. It will be the sole responsibility of the Compliance Panel.

Eucomed represents 22,500 designers, manufacturers and suppliers of medical technologies in Europe.