The Changing NHS: New Influences On Prescribing

Back row - left to right: Steve Mackenzie-Lawrie, Michael Beaman, Michael Warren Front Row - left to right: Jackie Harris, Rachel Farrow

Around 80 delegates packed the meeting room at Abbott Laboratories in Maidenhead for the last PM Society briefing meeting of the year, which examined the emerging role of groups within the NHS that have or will have a direct influence on the use and prescribing of products within that organisation.

The two speakers provided a good insight into the dynamics of the payer/prescriber relationship, together with practical advice on how to interact and work with these emerging groups - and what the changes mean with regards to the marketing and sales of products to the NHS.

Welcoming the audience to Abbott, Jackie Harris pointed out that this was the first PM Society briefing meeting to be held at the company's new home, which it moved into a year ago.

Michael Beaman

The first speaker was Michael Beaman, an independent pharmaceutical adviser. A pharmacist for over 35 years, mainly working in the NHS in both the hospital and PCT environments, more recently he implemented a new pharmacy contract and contributed to PCT prescribing plans to achieve the Turnaround Plan.

Setting the context, Michael took the audience through the various milestones which have led to the current situation: the 2005/6 NHS changes, the move to larger PCTs and SHA, Practice-Based Commissioning and the 'Turnaround plan' which he was involved in. This latter meant that PCTs were now having to manage within their budgets, with outside teams being brought in in some cases to manage this. This had received a cool reception in PCTs, with staff having to report daily, a move he described as "nonsense".

With SHAs becoming more focussed on strategy and performance management, and PCTs on both commissioning and providing services - and all of them different - Michael agreed that it is difficult for outsiders to keep up. "It must be harrowing for industry folk to know what's going on in the health service," he said.

On top of all of this the Wanless Report of 2007 (a Review of the 2002 Report), which led to reduced waiting lists, but alongside that a concern that salary rises had not led to productivity gains, had been followed by the Darzi Review, which is still ongoing, and starting to generate headlines during the political conference season.

So what has been the impact on local prescribing, and where does it sit - in the PCT, or with Practice-Based Commissioning GPs? "The jury is still out at the moment," he said, but he did suggest that the PCT still managed the budget; although the engagement with PBC GPs had led to a grey area.

What is clear is that budget issues mean that prescribing is an easy target - "visible and measurable", according to Michael. This means it is inevitably a target for savings. "That's unfair," he commented. "In general terms we should be prescribing more, not less."

Savings are being achieved through a number of initiatives, both national and local. Amongst the national initiatives with the greatest impact are statin switches (targeted to achieve an 80% use of simvastatin, a goal based on that figure being reached originally by just one or two PCTs); generics, including Category M, and medical and surgical items.

Michael suggested that some of the savings implied by these initiatives could be achieved. In an ambiguous way, for example statins being prescribed more widely than clinically indicated, thereby achieving the 80% simvastatin target. "It should be the clinical judgement of the GP - but does that actually happen?" he asked.

Local initiatives have included the medication review, dose optimisation and formularies and prescribing policies, which have become the cornerstone of local savings schemes in both primary and secondary care.

Locally, PCT recovery plans have underpinned - and had a big influence on - local prescribing influences. Prescribing committees, often jointly run with hospitals, formularies and 28 day prescribing where clinically justifiable, have all played a part. Meanwhile the managed entry of new drugs is critical to the industry.

Each stakeholder will have their own priorities: PCTs are driven by the recovery plans (and therefore making savings); hospitals are interested in shifting prescribing to primary care, whilst primary care HCPs will want to do what is best for the patients, which may not necessarily be budget driven.

Meanwhile on the national stage, the Government is also interested in achieving savings, and is driving this through metrics which compare the prescribing 'performance' of each PCT. Meanwhile national bodies such as NICE/NSF, PPRS and the Healthcare Commission monitor of PCT performance all play a part. The PPRS review by the OFT is likely to introduce a value-added measure into the equation.

In this context, Michael declared that there is a need to expand prescribers and relieve pressure on the medical profession as a whole, especially in the field of long-term chronic conditions, where increasingly more capacity is needed. He said that pharmacists have been a little slow in getting into prescribing, although nurse in both primary and secondary care were fulfilling that role in numbers.

One positive consequence of all this is that the expansion of prescribers will lead to better control, as the new prescribers would be "more compliant" than GPs, according to Michael. But the uptake was being hampered by IT issues, coupled with scepticism: nurses wanted to be nurses, he said, and pharmacists need a GP mentor, which is limiting take-up in itself.

Despite this, the availability of both medicines and prescribers is mushrooming, both through POM to P switches and minor ailment schemes, as well as a host of new gateways to prescribing: OOHS, Minor Injuries clinics, walk-in centres and GPs in pharmacies. "Where is it going to end?" asked Michael, "prescribing unlimited!"

Being a pharmacist himself, Michael then focussed on the new Pharmacy contract. Underpinned by clinical governance, it includes a stronger and more consistent approach to dispensing and public health, whilst enhanced services such as smoking cessation and EHC would be locally commissioned and funded by the PCT - and with no central funding, these services are sure to vary from PCT to PCT.

However, the Advanced Services outlined in the new contract are nationally funded, and linked to accreditation, and have led to some important changes (such as consultation areas). Meanwhile, initiatives such as the Medicine Use Review and Prescription Intervention could link into Practice-Based Commissioning.

So what impact has all this had on pharmaceutical advisors? The first is that of positioning - do they sit in the PCT or PBC groups? The answer to this one is that they are still within the PCT, but working with the PBC groups. The changes have led to questions about he viability of advisors, with many redundancies already pushed through. And to muddy the water still further, PBC groups could go to private sector advisors or even the industry itself rather than PCTs. Michael said that this was sure to affect relationships.

So who are the influencers? The answer is not simple, especially given that PCTs are all at different levels of development. But Michael said that alongside pharmaceutical advisors and GPs would be a new breed of commissioning manager, and the industry would have to know who they were.

Despite the changes, the key issue within the NHS remains that of 'silo'd' budgets: with the benefits of a particular prescribing policy likely to emerge in another budget (e.g. in secondary care savings), then convincing those holding the prescribing budgets of those very benefits is difficult, when there may be little direct benefit financially to that particular silo.

Michael finished by saying that after ten years of big increases in NHS budgets, there was unlikely to be much new money in the next few years, so that the NHS would have to live within its budget after 2008.

Michael Warren

The second speaker was Michael Warren, Head of Primary Care at Pfizer. Having spent 18 years as a general manager in the NHS, he has first-hand insight into the provision of hospital services and the roles and procedures associated with running a Primary Care Organisation. He now heads a team working with Pfizer's brand teams to align products to NHS clinical needs and imperatives, and to develop real partnerships with healthcare organisations and HCPs.

He started his presentation by asking the audience to take themselves back to 1984, asking how they would launch a new medicine. The answer being, of course, using a big field force aiming at GPs.

So what has changed? The first point Michael raised is that "it's all about money - all you have heard is that it's all about money." He illustrated this point graphically by revealing where the extra £19 billion pumped into the NHS over the past decade has gone. £6.6 billion went to NHS workers' pay; £5.9 billion went to 'other developments'; just £2.2 billion (12% of the total) went into medicines, and even this figure includes items such as surgical dressings and appliances, not only medicines.

And today, even the non-financial priorities are not about prescribing: the 18 week waiting lists, MRSA, long-term conditions, older people and smoking cessation head the list. "How do your products play into that environment?" he asked.

He also questioned the ethics of an NHS plan which calls for a £250 million surplus this year. "To me, this is an ethical dilemma," he said. "How can you have a surplus if you are making people wait? Why would you want to save money when there are people whose access to treatment is being denied?" But this is the reality.

Politics also plays a part, nowhere more so than in local commissioning in the four nations that make up the UK. Michael suggested that pharma companies have been traditionally Anglo-centric, pointing out that Scotland, Northern Ireland and Wales have very different health economies.

He also quoted the National Audit Office report on prescribing drugs in primary care, which found a huge level of waste, with an estimated £500 million of drugs thrown away by patients. His view is that patients often don't believe they need the medicine, and even if they do, no-one told them there would be side-effects. All of which points to the need for honest marketing by the industry, and honest conversations by prescribers with their patients

Michael reiterated Michael Beaman's point that the drugs budget is an easy target when it comes to cost-cutting. "It's the one thing the NHS can measure that stands still!" he joked.

Next he introduced what he called the 'Decision Continuum', and asked where on it the decision to use your product lies.

The point is that all the individuals shown influence the prescribing decision (depending on the therapy area), and thus the industry needs to be clear who is going to make the actual decision, and that is often different from case to case.

What is clear is that there are some key corporate bodies in the game, amongst them national organisations such as NICE, SMC and AWMSG, as well as sub-national ones which influence upwards. As well as PCTs and PBC groups in England, there are specialist commissioning bodies for high-end, high-cost, low-volume treatments, as well as the financial and public health input from the SHAs. The picture is extremely complicated.

And it's not simplified by the number of new players getting involved, although the extremely low take-up from new prescribers (Nurses, pharmacists, optometrists) means that this group has less influence than might first have been imagined. Lack of payment, "rubbish" IT and the fact that clinical governance is still not sorted out, means that numbers are very low, with many GPs regarding new prescribers as what Michael called "the handmaiden of the GP, there to deliver the Quality and Outcomes Framework".

Patient interest groups, however have an increasing influence about access to therapies and choice, and the industry must know and work collaboratively with the relevant ones. Likewise, private sector providers entering the market and creating formularies will "decide the fate of the industry's brands because they have to find a commercial balance."

"It's a web, and there is no easy way through it," Michael commented.

So what should the industry be doing? Relying on the old-fashioned rep/GP relationship is simply putting your head in the sand, and is not sustainable. So where on that continuum do you place your effort? "Be canny, and think about your brand," is Michael's advice. "Who would you go to to make it sell?"

The message is equally important. Don't rely on the baselines of efficacy, safety and tolerability, these should be a given. So what is the added value of the brand: does it 'fit' with health policy; can positive outcomes be demonstrated; does it fit the cost criteria? Where does it fit in the commissioning agenda?

If it does, it will gain support, and this is where the industry can get smarter. No longer do we as an industry control the prescribing agenda. So our marketing messages need to fit in with the NHS's agenda, and that means the individual agendas of each person on the prescribing continuum (and they will all be different).

Looking to the future, Michael said that he doubted that a National Tariff will happen, but that the industry should "be very afraid" of a pan-European NICE. He said that the power will lie "further up the food chain".

He finished his presentation on an upbeat note, saying that the industry could do it, "because we make great medicines, and we should be proud of it. We make medicines that work, save people and improve their quality of life - and we should stand up and continue to beat that drum."

Questions

The first question from the floor asked the speakers whether they thought that we were closer to the GP rep disappearing altogether. Michael Beaman answered by saying that people who are building relationships with the NHS now tend to be higher up the hierarchy; Michael Warren said that, in his opinion, the GP representative would never completely die, but that the industry would see consolidation.

Following on from that question, another delegate asked who should be sent to the new prescribers and decision-makers: reps or specialist NHS development teams. Michael Warren said that the industry should send the right person with the right competencies - it wasn't about a job title. Michael Beaman agreed, saying that the approach had to be much more targeted, and there was no 'one size fits all' solution.

The question of NHS budget 'silos' came up, with the questioner asking whether collaborative procurement hubs might solve the problem. Michael Beaman responded that it might, to an extent. "the big issue is taking money out of the system; it's never been done," he said, adding that the NHS Review may change that.

Another delegate raised the issue of MURs, asking whether they were just buzzwords. Michael Beaman disagreed, saying that although they were still underused, they could have real benefits, for example in terms of compliance and wastage.

The final question concerned increased collaboration between pharma companies and supermarkets, with the aim of increasing accessibility. Both speakers agreed that this was likely, and that the industry had to think about what services it wanted to provide. But they did point out that supermarket pharmacists were mainly driven by scrip count and productivity to support footfall into the retail outlets.

For the PM Society, Steve Mackenzie-Lawrie thanked both speakers, and Abbott for hosting the briefing, and invited input from members about what topics they would like to see covered in next year's round of briefing meetings.

Held on: 02/10/2007