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All things Pharma

The shape we’re in

THE RECENT PAPER from Sir Nigel Crisp, Commissioning a Patient-led NHS (27th July 2005), is one of the most significant health announcements for the pharma industry since Shifting the Balance of Power (2002).

Summary of Commissioning a Patient-led NHS and a few early thoughts (see italics) on its commercial implications:

 • Key DoH paper, covering the size, form and function of the English market environment to 2008.
   • Fewer but more strategic PCTs. Think of how your own company is “Fit for Purpose” and its degree of alignment with NHS customers – the surviving PCTs will demonstrate survivor behaviour.
   • Practice-based-commissioning – 100% coverage by October 2006. Think leaders and followers – identify the leaders early, understand their drivers – they too will be strategic. What will your PbC interface look like?
   • We are about to enter a period of lawless state – again. Focus on customer agendas, not structures.

HealthGain Solutions have modelled the configuration of the pharma customer market in a third Labour term in order to assist strategic planning and rightsizing of sales teams. It is important to anticipate not only the form, but more importantly the function and drivers, of payor and prescriber behaviour.
So what is driving yet another round of market change . . . and given all the so-called “modernisation” of the NHS, does it matter?
• What’s driven the announcement? Political imperatives. A 2.75% yearon- year efficiency saving has to be realised, equating to a £250 million saving in NHS spend by 2008. Split this out to PCT level, and you are looking at 15% of management and administrative costs in order to realis endgame
• Does it matter commercially? Yes – but as always, it’s a question of balance. The pendulum is swinging again . . .
In the last nine years, some industry ‘harbingers of doom’ have claimed that in a world of PCTs, there is no place for sales teams; three-year planning rounds mean that no new products will be funded during these cycles; and (perhaps the most recent misguided pronouncement) “In two years’ time GPs will have no influence” – a spectacularly misguided prophecy, given the establishment of Practice Based Commissioning, its inclusion in the 2000 NHS Plan and (to leave no doubt) the publication of technical guidance for the implementation of Practice Based Commissioning (PbC).
So where will the balance of power lie in the next five years? In terms of setting the strategic context, the key components of Commissioning a Patient-led NHS are:
  • What will PCTs do going forward
  • Where will the power lie in a PbC world?

PCTs – form and function?
There will be fewer PCTs: probably no more than 150, broadly coterminous with Local Authorities. But these PCTs will be the big boys, the ones who meet the “Fit for Purpose” review criteria that will be implemented over the next year to decide who stays and who goes.
The survivors will probably include those PCTs who have ‘thought outside the box’, been pragmatic, reached out and sought new partners to help them realise their targets – from private sector providers to HMO-style ‘case management’ (for example, the Trent and Birmingham and Black Country PCTs).
You could probably name the PCT survivors now. Yet they will not be announced until the “Fit for Purpose” review has been undertaken. The criteria that the PCTs will have to jump through hoops to satisfy include the ability to:
  • secure high-quality, safe services
  • improve health and reduce inequalities • improve the engagement of GPs and the rollout of PbC with demonstrable practice support
  • improve public involvement
  • improve commissioning and effective use of resources
  • manage financial balance and risk
  • improve co-ordination with social services through greater congruence of PCT and Local Government boundaries . . .
So it’s all the ‘same old same old’ – until you get to the next bit! • deliver at least 15% reduction in management and administrative costs.
At least Sir Nigel is being explicit about the real driver here.
After the fallout, this is what you can expect PCTs to do:
  • PCTs will ensure that patients have access to and choice between highquality health services, realising the Government’s commitment to reducing health inequalities and making sure that health services are delivered to local people. Capacity/waiting times will remain a key driver – so shape your messages around realising the 18-week wait target.
  • As custodians of their population’s health budget, PCTs are responsible for ensuring prioritisation and value for money in ways that have maximum impact on health and secure all necessary health services. More Priorities Committees for new treatments.
  • The PCT functions that can be provided by external agencies, partners [including the pharma industry: see the Pfizer Healthcare model] and consortia working on their behalf will remain as follows:
   – improving the health of the community and reducing health inequalities
   – securing the provision of safe, high-quality service
   – managing contracts on behalf of their practices and public
   – engaging with local people and other local service providers to ensure that patients’ views are properly heard and coherent access to integrated health and social care services is provided [keep working on Choice]
   – acting as provider of services only where it is not possible to have separate providers – and with arrangements for separating out decisions on commissioning from provider management
   – emergency planning.
Practice Based Commissioning
Practice Based Commissioning is perceived by the DoH as a way of devolving power to GPs and nurses in order to improve patient care. While PbC is a different model from Fundholding (it is more strategic and corporate, designed to drive out dysfunctional GP practices), it is also envisioned as a way of reengaging GPs with the vision of a primary care-led NHS, and of aligning local clinical and financial responsibilities.
Under PbC, GP practices will take on responsibility from their PCTs for commissioning services to meet the health needs of the local population. The commissioning practices and groups of practices (clusters) will have the following main functions: 
  • Designing improved patient pathways. Pulling interventions out of the hospitals – so think about sales force/nurse team configuration.
  • Working in partnership with PCTs to create community-based services that are more convenient for patients. As above, plus GpwSIs.
  • Responsibility for a budget delegated from the PCT that covers acute, community and emergency care. And probably the prescribing budget. Who needs to engage with those who influence this process?
  • Managing the budget effectively.
    – Remember that clusters can keep 100% of efficiency savings. Where will the soft targets lie?
    – Fundholding demonstrated that practices were willing to decommission hospital services. Imagine the pressure on capacity now we have an 18-week wait target by 2008!
    – Assume more pressure in prescribing budgets – and remember that the easy cost-pressures have been addressed already.
Under PbC, GPs will not be responsible for placing or managing contracts. That will be done by PCTs on behalf of practice groups, with back office functions including payment administered by regional/national hubs. GP practices will also receive management support, the extent of which will depend on the number of practices involved.
Given the strategic importance of commissioning to the modernisation agenda, the DoH expects to see PCTs make arrangements for 100% coverage of PbC by no later than the end of 2006.
SHAs – form, function and future?
   • Performance managing PCTs and the NHS local public health function, and working closely at a regional level with the Department’s Regional Directors of Public Health in the Government Offices of the regions.
   • Tertiary-level commissioning when this cannot be undertaken by PCTs.
   • Taking NHS trusts to foundation status.
Timetable for changes in commissioning functions
August to mid-October 2005: SHAs review their local health economy’s ability to deliver the commissioning objectives. Submit plans to ensure they are achieved, including reconfiguration plans where required.
March 2006: first wave of enhanced PbC implemented.
December 2006: PCTs have arrangements for universal coverage of PbC in place.
April 2007: SHA reconfiguration complete.
December 2008: Changes in PCT service provision complete.
We hope you have found this overview and interpretation helpful. If you would like to discuss the implications in more depth, please do not hesitate to contact Andrew Platten or Angela McFarlane: telephone 01635 277200, e-mail Angela.mcfarlane@healthgain.co.uk


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