Spot the Commissioner

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 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.