Reforming the NHS:

A culture of choice

As the NHS is challenged to provide greater patient choice, a new commissioning culture is emerging. What does this mean for the healthcare sales professional? Chris Ross reports.

We all know the NHS is changing – but do we know how it is changing and, crucially, how it affects us? This month, On Target begins a four-part series looking into the Government’s reform agenda.

The vision for change was laid out in the DH’s 2005 publication Creating a Patient-Led NHS, which outlined four strands of reform: demand-side, supply-side, transaction and system-management reform. Our new series Reforming the NHS takes a detailed look at these four areas. We start with demand-side reform.

Restructuring the system

The wider reforms are designed to create a business-focused health service. The NHS is in deficit, hospitals are full, the population is living longer and the healthcare budget cannot withstand the pressures. What’s more, the single-supplier service that is the NHS, founded on a principle of ‘free for all at the point of need’, was not built with such a situation in mind.

The Government wants to introduce competition into the market to improve quality, drive down costs and provide choice for healthcare consumers. Central to these aims is the introduction of the traditional supply and demand model of economics that dominates other business sectors, but has always been absent in healthcare. Previously, if a service needed commissioning, it would be commissioned to the local hospital. The desire to move away from this model has heralded a wave of policies under the umbrella of ‘demand-side reform’.  Demand-side reform focuses on giving patients a stronger voice in deciding what healthcare services they need, and input into how these services are delivered. Patients will be offered a choice of service provider, such as an independent treatment centre, a community or practice-based service and a foundation hospital. The local hospital, stimulated by the competition, may well be able to offer a more efficient service. In a sense, local hospitals will now be competing for patients. The benefit for the patients will, hopefully, be speedier and thus more effective treatment.

So demand-side reform is about establishing the philosophy that patients should have a choice in the way they access healthcare services, and creating a framework that enables choices to occur. This philosophy is supported by supply-side reform, which we will look at next month.

For demand-side reform to succeed, the process of commissioning services in the NHS needs a radical overhaul. As such, the reforms have also set about implementing a robust framework for an improved commissioning function.

Think nationally, act locally

Many of the headline initiatives of demand-side reform have already taken place. Last year, the NHS was reshaped to provide a platform for implementing change. The boundaries of the Strategic Health Authorities (SHAs) and Primary Care Trusts (PCTs) were redefined, creating bigger but fewer bodies to govern the system. The purpose of this restructure was to strengthen the commissioning functions of PCTs and, in the process, to give them the support and infrastructure necessary for them to design services that could deliver local healthcare priorities. These enlarged PCTs are much stronger commissioning bodies, covering larger patient populations.

Demand-side reform also introduced a policy with which we are all familiar: practicebased commissioning (PBC). PBC enhances the commissioning function at the local level within PCTs and satisfies the patient choice element of demand-side reform.

Through PBC, PCTs can listen to patients’ requirements and design services that meet their needs. PBC adds the vital ‘patient voice’ to the commissioning process. The DH expects PBC to become an important mechanism through which the number of hospital referrals can be reduced and replaced by an increased provision of healthcare services nearer patients’ homes. Budgets will be delegated to practice level, but PCTs will retain strategic responsibility for the commissioning process. .

A new commissioning culture: responding to demand

Alongside this, demand-side reform is precipitating a new culture of commissioning. Traditionally, commissioning has always been undertaken by virtue of block contracts, awarded almost entirely to the local hospital.

Commissioners purchased services that delivered a given number of outpatient appointments, leading to an output-led service. For example, a commissioner might buy a service that guaranteed 100 cataract operations, i.e. 100 pre-agreed outputs.

In the new NHS environment, commissioning will be outcome-based. A commissioner cannot award a bulk contract to a local hospital based on volume because, given the role of patient choice and the anticipated range of service providers, the volume cannot be guaranteed. Instead, commissioners will ask service providers to guarantee outcomes. This cultural shift empowers the purchaser and commits the provider to agreed levels of quality and tangible results. Together with PBC, this creates a market that is able to respond to demand.

The impact on the sales professional

What does all this mean for the field force? Well, it signals the emergence of a new customer group for the sales professional: the NHS Commissioners. Also operating under a range of other titles such as Modernisation Directors, Directors of Strategy and Directors of Service Provision, their importance cannot be underestimated.

Commissioners will make key decisions about how money is spent on service provision. Since the services they commission necessarily involve products, decisions made by commissioners will undoubtedly affect how medical technologies are used. Consequently, sales professionals need to develop a different set of messages to address commissioners, based on an understanding of their priorities and how specific products help them achieve their objectives in the NHS environment.

A commissioner has a range of objectives, the most fundamental of which is to improve health outcomes in a cost-effective manner. The opportunity for the sales professional is to identify how to persuade the commissioner to change a service in a way that delivers a cost saving and improves health outcomes.

Defining clinical pathways

Professor Sir Michael Rawlins, Chairman of NICE, has identified hysterectomies as an area where devices can help to redesign a service. In a recent interview with On Target, he pointed out that some devices reduce the need for major surgery: “For example, for women with heavy periods, there are ways of destroying the lining of the womb that don’t involve having a hysterectomy. The NHS does 50,000 hysterectomies a year.

Women stay in hospital for a week and end up heavily scarred. There are now implantable devices which burn the endometrium and destroy it. These can be done as a day case with no surgery, and women don’t end up scarred.”

Medical technology can to help save the NHS money by changing care pathways while delivering improved health outcomes. The challenge is to identify where your product can make a difference and help to provide choice.

Clearly, medical technology can help to save the NHS money by changing care pathways while delivering improved health outcomes. The challenge is to identify where your product can make a difference and help to provide choice.

The key questions are:

• Can your product be delivered as part of a community-based service?
• Will it have a positive impact on waiting lists?
• Will it enable secondary care patients to be discharged earlier?
• Does it prevent people going into hospital?
• Can you wrap up your product in a package of care that will help a commissioner meet a target?

The bottom line

In the spirit of outcome-based commissioning, hardline purchasers will be business-orientated and driven by achieving their ultimate objective: health gain. The modern commissioner is not concerned with who provides a specific service, but seeks assurances that it will be provided to an agreed specification and deliver agreed outcomes. If your product can become a part of such a service, the opportunities for growth will be vast.