There are now dozens of articles in the pharmaceutical and NHS journals describing what the new GP Contracts are and how they will operate post April 2004, this article seeks to examine what the commercial implications might be in relation to field sales activity and the importance of understanding the altered dynamics brought about by the outcomes focused contracts.

Background

Firstly, a reminder as to what the contracts mean. There has been something of a feeding frenzy around the new General Medical Services (nGMS) contract, but remember more than 40% of GPs will be paid under PMS so it is important not to focus exclusively on nGMS but to regard nGMS as part of wider contractual and ways of working arrangements in the NHS and only one of two ways to reimburse GPs. Now all the negotiations are over and the ‘aspirational’ bids are in, just who is “going to make it happen” and what are the worries? Of course, there are many stakeholders in the implementation process, the GPs, Practices, LMC’s, PCTs, SHAs, the Modernisation Agency, to name but a few. But, in respect of the detail that needs to be mobilised before April 1st 2004 there are 3 key groups: the GPs, the LMCs and the PCTs.

From a GP/practice perspective the tasks between last summer and April this year lies around deciding on how they wish their contract with the PCT to shape-up:-

• Do they want to opt out of additional services (eg: Vaccs and Imms, cervical screening)

• Do they want to opt-out of out of hours (OOH) – 1 PCT I spoke to anticipated 85% of practices will opt-out

• Which national enhanced services (eg: depression, drug and alcohol misuse, MS) might they want to opt into

• Which local enhanced services to they wish to opt in to.

There has been a tidal wave of advice to GPs in respect of where their priorities might lie in order to ensure they get the most financial gain from the new contract. For some, delivering on just a few of the possible high revenue-earning priorities outlined in Tables 1 & 2 will be easy because they are already delivering on NSFs, targets, implementing NICE guidance and are fully computerised. For many the new contract represents a highly prescriptive method of payment, which will necessitate significant behavioural change at professional and practice level.

It is the PCTs however, who will face the biggest challenge in respect of implementation. In addition to the existing responsibilities of local health strategy delivery, financial balance and delivering sustainable local health improvement, or even worse an imminent CHAI review, (or recovery from a CHAI review!) they now have to plan the roll-out of the new contract. The pharmaceutical industry therefore must proceed with caution ensuring that PCTs are engaged in the process of driving through initiatives in the name of nGMS and PMS as they remain the payors, and although it will take many months for the new contractual schemes to bed in, there will come a time when the PCT decision makers will take an interest in points generating projects for general practice that increases their infrastructure and prescribing costs.

New General Medical Services (nGMS) Behavioural Changes

Last year HealthGain Solutions worked with industry leaders developing their strategic response to the new contract. Naturally, most have focused on the quality components; some are becoming attracted to the National/Local Enhanced Services component. Michael Sobanja NHS Alignment Director at HealthGain Solutions believes “our clients are developing integrated solutions between PCTs and GP practices, rather than tactical quick fixes at practice level alone. As far as possible we believe solutions should align to the “ payment by results” system. The guiding principle for marketers who really believe in addressing customer need should be to work on initiatives that help the NHS meet its strategic objectives, the contract itself will see dramatic change in local policy and prescribing patterns”

Programmes which PCTs and practices with whom we are working with value, include: –

• Supporting the training and development of GPwSIs

• Project teams undertaking gap analysis of specific quality areas at practice level and developing action plans to address them

• Project managers to develop and implement action plans once LES priorities have been agreed

• Medicines management review strategies and team resource to do the work

• Facilitating patient group meetings to drive the patient agenda.

We asked a number of GPs and PCT PEC or Board members about issues during the implementation phase and have identified a number of common concerns. Dr Tony Brzezicki, a GP, and Prescribing and Cancer Lead from Croydon PCT explains “The clear objective within the new contract is outcomes, the concern for the PCT therefore is that an outcomes focused practice is not necessarily drugs focused, therefore the drugs guidance and formularies may go out the window”. He continues, “An example of my concern will be if a GP wants to get to target quickly in respect of cholesterol lowering then they will go to a higher and more expensive statin dose level earlier than recommended by local guidance, this could lead to a lack of goal congruence between the individual GP, practice and PCT”. Dr Duncan Jenkins, (Specialist in Pharmaceutical Public Health, Dudley PCT) sees the contract creating even more pressure on PA resource for the PCT “..where services such as prescribing support have been commissioned by the PCT, in the future, employment may be secured by the practices, especially as the opportunity for a pharmacist to become a practice partner evolves”

Impact on Field Sales Activity

It is clear then that the nGMS and PMS contracts, whilst creating opportunities for improved care and joined-up services, creates a selling environment that is complex and evolving. GPs and members of the practice are focusing very much on delivery and this presents the pharmaceutical industry with some real barriers. Dr Jace Clarke, a GP and Chair at Horsham & Chanctonbury PCT comments “Everyone in Primary care is totally focussed on the new contract at present so difficult to get anything done unless you are ill”. Dr Clarke’s comment is not an isolated one; many GPs throughout the country will feel the same way. It is also possible that GPs will favour seeing representatives from companies who have valuable information and perhaps initiatives that help them reach their contracted goals in the ten areas of most interest to them. Some local service delivery issues linked to quality and outcomes framework (e.g. CHD, Diabetes, COPD) may determine which companies are more attractive to receive calls from. As a natural progression from this, will the appointment management system in the practice be set up in such a way to allow the practice to earn more points within the outcomes and delivery elements of the contract? Will this mean that practices will prefer to open their diaries only to pharmaceutical companies who have a drug or service that will assist in this endeavour, speculation I know but this is a good time to think the unthinkable.

There are of course many more examples of GP and PCT concerns and indeed opportunities. As an industry, we must continue to measure where PCTs are with the implementation plan and its rollout post April 2004 and ensure we look beyond the obvious alignment opportunities and develop innovative solutions through really understanding the challenges facing all stakeholders, not just the GPs.