Tiers of influence

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 The NHS may be changing, but some challenges remain the same. The battle pharma companies face is not simply to identify Key Opinion Leaders at local, regional, national and even international level, but to understand the different roles these individuals play and how they interact to create a Market Access influence network. Richard Gray explains.

The complexity of introducing a new drug into the NHS with a view to open up prescribing at local level has changed quite drastically over the past few years. The shift in emphasis from clinicians to payers and the growing significance of national and regional bodies has fundamentally transformed, not only the stakeholders, but also the shape of teams within many pharmaceutical companies.

Most notable has been the expansion of pharmaceutical sales people operating at a more senior level within their customer accounts. Companies now have to consider the key national organisations such as Health Technology Assessment (HTA) bodies and the influence of patient advocacy groups and charities, as well as the explosion in regional decision makers, from Medicines Management committees to regional procurement organisations.

Furthermore, it is becoming increasingly clear that national boundaries are being blurred. While each European country will undoubtedly continue to make its own drug approval decisions for some time to come, there is growing communication and collaboration between national HTAs. There is also evidence that local clinicians in the UK are increasingly as likely to consider the recommendations of SNC and SIGN in Scotland, IQWIG in Germany and AIFA in Italy as those of NICE in England, or the All Wales Medicines Strategy Group (AWMSG) in Wales.

This extension of the sphere of influence across national boundaries now creates the need to track the interaction of KOLs across Europe; to highlight specific disease areas in which collaboration and communication is greater; and to understand the extent of individual and HTA influence on clinicians.

Expanding remit

One of the greatest shifts now facing pharmaceutical companies is the need to significantly ramp up activity at a strategic, national level. While historically, lobbying parliamentary groups and collaborating with charities was the role of a single Policy and Affairs Manager, today this role requires an entire team. There are now large numbers of national bodies, including HTAs to consider. Patient advocacy groups and charities also have huge influence, taking a key role in many HTA committees, influencing care pathways and, in many cases, leveraging significant financial resources to lobby parliament.

Many of these individuals will have multiple other roles at regional and local level, offering many opportunities for pharmaceutical company interaction – creating the need for a strong Market Access team able to track interactions at every level and across these diverse spheres of influence. In fact, there is evidence to suggest that pharmaceutical companies who do not track and manage individual interactions at all levels of their organisation may actually be harming the reputation of their company at a regional or local level. A traditional pharmaceutical sales call made by an inexperienced representative on a GP may not immediately trigger alarm bells, but if that GP is the PCT Lead on a purchasing or prescribing committee, damage to the relationship may occur.

Indeed, in addition to increasing the expertise and experience within Policy and Affairs, pharmaceutical companies are having to address the new regional tier for the first time. Whilst most organisations will have, in the past, made little attempt to build relationships with the Strategic Health Authorities (SHA), preferring to work with clinicians at Primary Care Trust (PCT) and GP level, the growth in regional procurement strategies is creating a new group of stakeholders.

With the emphasis on cost containment, the remit of regional procurement has expanded from the traditional focus on disposables to incorporate drug acquisition. These stakeholders are primarily focused on finance and are looking for discounts and opportunities to collaborate with other regional bodies to further drive down the cost of drugs, which requires pharmaceutical companies to create and deliver individual messages.

Clinical relevance

In addition, there are a number of emerging disease specific groups, including cancer and cardiac networks, that are operating at a regional level. The UK Medicines Information Centre has 14 regional centres and has a huge influence on prescribing; as does the National Prescribing Centre, which works alongside NICE to distil and assess new drug evidence and provide advice to prescribers.

Furthermore, many of these regional groups work together: decisions made by one Commercial Support Unit (previously Procurement Hub) or Medicines Management group are often repeated across the country. It is therefore essential, not only to identify these groups, but also to track decision making and assess which groups are leading the way in both procurement strategy and pharmaceutical decision making.

It will also be important to reinforce the work done at national level with patient advocacy bodies and charities at both a regional and local level. Most of these organisations focus their attention on national bodies, and undertake local patient-centric communication. There is therefore a key role for pharmaceutical companies to ensure joint projects, messaging and disease specific developments are clearly disseminated to the new regional stakeholders.

Political change

Given the efficiency drive that must now be put in place in order to attain the estimated £20 billion savings required across the NHS, it is also clear that rationalisation at management level is likely. The Government’s new White Paper promises a major reorganisation of the NHS, with PCTs and SHAs facing a slow death. The long-term impact of this remains unclear and, with change likely to occur in steady phases, pharma’s customer-base and targeting strategies will not change overnight.

The reforms, combined with a need to drive greater cost savings at every level of the NHS, will place further emphasis on the regional procurement bodies. Throughout this time it will be essential to track changes, assess the impact on KOLs and networks of influence and rapidly assimilate the implications of new strategy, such as a renewed emphasis on generics or a stronger adherence to the QIPP agenda.

Irrespective of the speed of change and moves towards a clinically-led health service, the influence of payers will continue. However, it is also important to recognise that this influence is inconsistent. Disease areas typically treated in primary care, such as hypertension, are highly influenced by both the HTA and PCT. In secondary care and some specialist areas, clinicians retain control. And there are also local drivers that reflect the health needs of local communities and, in some cases, the personal goals of that individual.

In this complex, fragmented marketplace the goal is not just to identify the new breed of non-clinical stakeholders – although this is essential since the number of non-traditional stakeholders has increased significantly – but also to understand how these stakeholders interact at a national, regional and local level and to determine an accurate network that spans these tiers of influence.

Richard Gray is Commercial Director (CCI) for Cegedim Dendrite, responsible for their

segmentation and targeting services and KOL / stakeholder mapping.