Devolved Nations – Making a difference to Sales Strategy?

PHARMACEUTICAL COMPANIES operating within the UK are now faced with the need to work within the four different healthcare systems operating within England, Scotland, Wales and Northern Ireland. In order to ensure that the activities of the sales team on the ground are aligned to the NHS there is a need to fully understand their environment and tailor national strategies accordingly. This article explores the recent developments within the three devolved nations and makes some suggestions on how sales team activities may need to be adapted to make the most of any local opportunities.

Scotland
A New White Paper
‘Partnership for Care’ is the latest white paper to be published by the Scottish Executive and it outlines what the political plans are to provide Scotland with an NHS fit for the 21st century. In the summary, Malcolm Chisholm, Minister for Health and Community Care, clearly outlines the cultural change that needs to take place that will result in the patient being placed at the centre of care. This will be achieved by the devolution of power to frontline healthcare workers and the redesign of services that will improve integration and partnership and result in patients experiencing a better and quicker service.

The key points from the white paper are summarised below:

  • Unified NHS Boards, abolition of NHS Trusts, and new requirements to devolve authority to frontline staff and to involve professionals.
  • New Community Health Partnerships (evolving from Local Health Care Co-operatives), more accountable to local communities, better matched with social work services and better able to represent local interests within the NHS Boards.
  • A new Scottish Health Council to involve the public in NHS Scotland.
  • A Change and Innovation Fund to help NHS Boards improve services for patients.
  • A new guarantee of treatment on time, initially for certain heart surgery but to be extended to services with national waiting time targets. New clinical and local service targets.
  • A Patient Information Initiative and a new complaints procedure to give patients and carers better information and a stronger voice.
  • A radical approach to improve health – a Health Improvement Challenge focused on four groups; children in early years, teenagers, people at work and communities.

Sales representatives working in primary care in Scotland will have been working closely with Local Health Care Co-operatives (LHCCs) in the past and the new white paper describes how these groups are likely to evolve into Community Health Partnerships in the future. These changes are required to ensure that the new Community Health Partnerships become fully involved in service planning and delivery and are able to undertake the following activities:

  • Ensure patients and a broad range of healthcare professionals are fully involved in local decision making
  • Establish substantive partnerships with Local Authorities
  • Have greater responsibility and influence in the deployment of NHS resources locally
  • Play a central role in service re-design locally by ensuring the appropriate integration of primary and specialist services
  • Play a pivotal role in delivering health improvement for their local communities

When re-designing local services, the Health Boards and Community Health Partnerships will be required to adopt a ‘whole systems’ approach which will entail clearly identifying the patients experiences when using NHS services, identifying any duplication or gaps in the service and then defining evidence-based best practice to address these issues. Consequently, there will be a need for a close partnership between primary and secondary care providers and also increasingly, social services and local authorities. It will be those teams of sales representatives who are able to work seamlessly between primary and secondary care and who are able to discuss this process locally and offer services and solutions to help implement service re-design e.g. integrated care pathway development, that will receive a favourable response from the new Community Health Partnerships.

Measuring the quality of NHS services in Scotland
NHS Quality Improvement Scotland (NHSQIS) is a new body that was formed in January 2003 through merger of the existing clinical effectiveness organisations:

  • Health Technology Board for Scotland (HTBS)
  • Clinical Standards Board Scotland (CSBS)
  • Scottish Health Advisory Service
  • Nursing and Midwifery Practice Development Unit
  • Clinical Resource and Audit Group (CRAG)

The purpose of NHS Quality Improvement Scotland is to improve the quality of healthcare in Scotland by:

  • Providing advice and guidance on effective clinical practice
  • Setting standards and monitoring performance
  • Making recommendations for service improvements

In order to achieve these objectives, NHS Quality Improvement Scotland will perform the following functions:

  • Sharing information about good practice
  • Sharing lessons from adverse events
  • Advising on the value for money of health interventions
  • Reducing variation in clinical practice through advice from health technology assessments and commissioning guidelines
  • Conducting audits and collecting and publishing clinical performance data
  • Setting clinical and non-clinical standards relating to all aspects of patient experience.
  • Reviewing and monitoring performance through self-assessment and external peer review, and investigating serious service failures
  • Supporting implementation of clinical governance in NHS Scotland

This makes this organisation very influential – it is the equivalent of the National Institute for Clinical Excellence and the Commission for Healthcare Audit and Inspection merging in England – and it will be imperative that anyone working in Scotland is fully conversant with its working and recommendations.

The Scottish Medicines Consortium (SMC)
This is probably the biggest hurdle for the pharmaceutical industry in Scotland and therefore the industry needs to formulate a strategy for engaging with the SMC. The remit of the SMC is to provide advice to NHS Boards and their Area Drug and Therapeutics Committees across Scotland about the status of all newly licensed medicines, all new formulations of existing medicines and any major new indications for established products. A sub-working group of the SMC has been formed called the New Drugs Committee and it will advise and make recommendations on the issues surrounding newly licensed products to the SMC. Any company launching a new product must complete a New Product Submission form and the SMC aim to make a recommendation as soon after the launch of a product as possible, full guidance notes describing how manufacturers should engage with the SMC are available on their website. The SMC meets monthly and a full list of members can be found at www.htbs.co.uk/smc/member.

Two examples of recent SMC advice are given below:

Antidepressive X
Indication: Major depressive episodes.
Advice: Recommended for use in NHS Scotland.
Reasons for advice: “Antidepressive X has been shown to be as effective as citalopram in short-term use and the health economic model submitted suggests that it is also cost-effective. However, the resource usage assumptions and clinical evidence underpinning the model are not robust and no clear benefits are demonstrated over the parent product – citalopram or other effective and cheaper agents.”

Combined Oral
Contraceptive Y
Advice: Product Y is not recommended for use within NHS Scotland.
Reasons for advice: “There is no evidence that Product y, a new combined oral contraceptive (COC) pill has effects superior to other standard strength COCs on acne, pre-menstrual symptoms or well-being. A statistically significant favourable weight change of 0.3 – 0.7 kg compared to a standard strength COC (over a period of 26 cycles) comes at a substantially increased cost. There is no evidence that patients who discontinue other COCs because of weight gain tolerate Product y any better. Product y is substantially more expensive than competitor products and provides little additional benefits for this extra cost.”

The Minister for Health and Social Care has publicly stated that: “NHS Scotland should take account of the advice and evidence from the SMC and ensure that recommended medicines are made available to meet clinical need.” Therefore, knowledge of SMC recommendations is a pre-requisite for anyone working in Scotland. A full list of SMC recommendations are available on their website (www.htbs.co.uk/smc) and again it will be extremely important for all representatives working in Scotland, as well as their Marketing colleagues, to regularly review the website as it also lists the dates when future guidance will be issued as well as current guidance. On a more tactical level, local teams will need to identify who is responsible for implementing the advice within the Community Health Partnerships.

Wales
Local Health Boards
On April 1st 2003, the 22 Local Health Boards (LHBs) in Wales became statutory bodies replacing the five health authorities and 22 Local Health Groups (LHGs) that previously existed. The LHBs are coterminus with the Local Authorities which means that there is likely to be closer integration of health and social care from the start. Their key roles are defined as:

  • Corporate and Clinical Governance
  • Securing and Providing Primary and Community Health Care Services
  • Securing Secondary Care Services
  • Improving the health of communities
  • Partnership working with local authorities and Trusts to ensure effective commissioning of services
  • Public engagement to ensure that the public voice is considered in all local service developments
  • The provision of primary care services

LHBs will have a chair who is appointed by Jane Hutt, Minister for Health and Social Services, four officer members (Chief Executive, Finance Director, Medical Director and Nurse Director) and up to 17 non-officer members who will include the following:

  • Up to three GPs
  • 1 pharmacist
  • 1 dentist
  • 1 optometrist
  • 1 nurse
  • 1 allied health professional
  • 1 specialist in public health
  • Up to 4 local government nominees including an elected member and a senior social services officer
  • 2 nominees of local voluntary organisations
  • 2 lay/community members, one of whom must be a carer

It will be important for pharmaceutical companies to identify who the members of LHBs are so that they can discuss effectively local priorities with them. At the time of writing however, the LHBs appear to be formulating their own guidance on working with the pharmaceutical industry and are currently not entering into any joint working relationships. This means that whilst future guidance is being developed any joint working with the NHS in Wales is likely to be more successful when it can be developed at a GP practice or individual Trust level.

The All Wales Medicines Strategy Group (AWMSG)
The All Wales Medicines Strategy Group held its inaugural meeting in October 2002 and the remit of this group is, “to provide advice to the Minister for Health and Social Services in an effective, efficient and transparent manner on strategic medicines management and prescribing.” It aims to reach a consensus view on medicines and management issues, particularly those affecting both primary and secondary care and its main functions are to:

  • Advise the Welsh Assembly on the development of a prescribing strategy for Wales
  • Advise the Welsh Assembly of future developments in healthcare to assist its strategic planning
  • Develop timely, independent and authoritative advice on new drugs and on the cost implications of making these drugs routinely available on the NHS
  • Advise the Welsh Assembly on the implementation of a range of strategic recommendations from the Prescribing Task and Finish Group

This last point is very important because the Task and Finish Group report included the following recommendations for discussion:

  • Sponsorship or direct employment by the industry of service-based posts should cease
  • Pharmaceutical sponsorship for staff training should be indirect through a generic fund rather than, as at present, through direct provision and funding
  • Where there is justification for the deployment of specialist nurses then they should be funded by the NHS. Existing sponsored nursing post which will be funded by a transfer from primary care drugs budget within the unified Health Authority allocations

The minutes of the AWMSG meetings are available on their website and it would appear that so far no further consideration has been given to these recommendations but it will be vital for anyone working in Wales to regularly review the minutes of the AWMSG for any further developments. The group meets quarterly and any pharmaceutical company launching a new product must complete a Therapeutic Development Assessment form ahead of the product being launched which is then considered by the AWMSG and a recommendation made soon after the launch of the product. AWMSG membership includes representatives from the industry and a full list of the members of the group can be found at www.wales.nhs.uk/awmsg.

Northern Ireland
The current uncertainty over the future of the Northern Ireland Assembly has inevitably had an impact on the speed at which the NHS has developed compared to Scotland and Wales and therefore very few changes have been made recently. The NHS locally is managed by 4 Health and Social Services Boards (HSSBs) who commission and purchase health and social care services for their local population on behalf of the Department of Health, Social Services and Public Safety.

Local Health and Social Care Groups
15 Local Health and Social Care Groups (LHSCGs) have been formed to take over from the previous GP fund holding arrangements and each group covers a population of between 60,000 – 200,000. LHSCGs are responsible for the planning and delivery of primary and community care and also contribute towards commissioning decisions made by their local HSSB. In the longer term, LHSCGs will take on greater responsibility for commissioning and will also receive delegated budgets.

The management board of each LHSCG consists of the following members:

  • 5 representatives from local Community Trusts and HSS boards (including at least 1 nurse, 1 social worker and 1 allied health professional)
  • 1 local acute Trust representative
  • 5 GPs
  • 1 nurse
  • 2 community/service users
  • 1 social worker
  • 1 community pharmacist
  • 1 Allied Health Professional
  • 1 LHSCG Manager

Therefore, it is important for representatives working within Northern Ireland to access these key people as in the future they will be involved in making more decisions around the commissioning of local NHS services.

Conclusion
This brief overview of recent developments within the NHS in the devolved nations demonstrates that the pharmaceutical industry really is operating within four separate health systems and these are summarised in Table 1. It is important to ensure that marketing strategies are designed to reflect the difference and support local sales teams in responding to local developments and adapting their tactical plans accordingly. Only by regularly tracking the developments and modifying strategic and tactical response will success follow.