The Changing NHS: Practice-based commissioning for pharmaceutical marketeers
The second in the PM Society's series of three briefing meetings for pharmaceutical marketers on the changing NHS took place at Altana Pharma's headquarters in Buckinghamshire, with vice-president of the PM Society Steve Mackenzie-Lawrie introducing the speakers. On the topic of practice-based commissioning (PBC), delegates heard from Dr Lisa Silver, a GP and PBC lead for a consortium of eight practices, and David Southern, senior brand manager, NHS marketing, at Napp Pharmaceuticals.
(l-r) Julian Trimming - Nycomed, Dr Lisa Silver, David Southern, Mark Scrutton - Nycomed
On 17 May 2007, Secretary of State for Health, Patricia Hewitt MP, made a speech from which no one was left doubting her commitment to PBC as a key NHS reform. 'If you thought PBC was another fashion that might go away - it's not, and you need to be part of it,' she asserted. To those GPs practices yet to sign up in support of PBC, her message was also unerring: 'The world is moving forward and you are about to be left behind.'
Speak to people working within the system and it wouldn't be an asinine assumption that the Health Secretary is using sturdy language because, despite her keen show of enthusiasm for it, PBC is actually stalling in the gates.
David Southern opened by showing a handful of quotations taken from Pulse, a popular newsletter for medics, all of which indicated that PBC is woefully slow in catching on. The government tells us that 90 per cent of GP practices are now on board, but this claim cannot be accepted at face value.
According to OECD data, more of us are living longer, which of course is good news. The flip side from the health service's point of view is highlighted by research from Imperial College, indicating that as people exceed the age of 65 the cost of keeping them in rude health rises exponentially. This fundamental fact is the ruthless driver behind the government's introduction of PBC.
We only have a finite amount of money and if PBC doesn't start rationing the way in which its spent, an equivalent measure will be brought in that will. Hewitt is adamant however: 'In part, making PBC a reality requires GPs to realise if you don't grasp this opportunity, others will.'
David pointed out the imbalance in the DoH's timing of reform introduction, whereby supply side came much earlier than reform of the demand side. This means that PBC is two years later than expected, which puts pressure on the system to match up to relatively sophisticated supply processes already in place.
Within demand side management however, PBC - and notably the GP commissioning process - is the most important part: the way in which commissioners manage their resources and decide where they're going to spend money is vital to the success of the NHS. In pharma, we need to appreciate the key issues from the commissioner's perspective.
- Which issues do commissioners see as the most important?
- What impact is any new service or technology going to have on cost?
- Even if cost is increased, will efficiency, or the patient experience be improved?
While PBC isn't really yet in operation, being ready with appropriate healthcare service and product solutions when PBC does finally become accepted and relied upon universally will also stand pharma in good stead to become a bespoke partner in the commissioning process. We need to keep just one small step ahead of the system, so that we're adding value as it develops. We need to understand the commissioning process in detail and how PBC commissioners will build business plans. We need also to develop the tools that will enable commissioning and, importantly, be prepared to partner more than we do already. This is a challenge in itself, requiring pharma to rethink its work ethic to some extent.
What do I mean by partnerships?
Pharma needs to be able to partner all colleagues across the NHS, including Foundation Trusts, secondary care providers and private suppliers, PCTs, GPs and other commissioners, consultants and experts in any particular healthcare area. Creating unison within this wide range of customers however is quite a skill, a key element in which is actually getting each of these customers to talk to each other; it isn't that they don't want to, but they're not used to it and so it doesn't happen very often. We should therefore facilitate these conversations.
Also, we ought to familiarise ourselves with all other suppliers to the NHS. It will become increasingly likely that Trusts will want to work with several suppliers simultaneously on any service, so we should look to connect with equipment suppliers, other suppliers of drugs etc, which will enable us to offer a portfolio of interventions and skills to commissioners.
As reliance on PBC starts to grow, we can help commissioners do their job by researching and explaining what's happening in a marketplace: provide the facts - how many patients are in the marketplace they're looking at? What resources are those patients using? Which specific issues can a new service tackle in any sector? How will these services work and how can we start generating demand within them for our own interventions and products?
Ultimately, PBC (or something like it) is here to stay for the foreseeable future. We need to help create an environment where our products can thrive and where appropriate patients present themselves at the appropriate time to be using our drugs. This is how our products and service offerings can be most effective and most helpful to the NHS. Our challenge is to prepare to partner with NHS and other non-NHS operators, and help our customers in becoming efficient and effective commissioners. Start by understanding in detail their fundamental challenges.
Dr Lisa Silver - PBC from the frontline
Dr Lisa Silver, a practising GP and PBC lead, was straight to the point on how PBC is rolling out among doctors: "If I was to invite my colleagues to a meeting about PBC, I would be the only one there with the sandwiches. Nobody would turn up."
GPs may see thousands of patients in any typical month. They don't have time to do PBC and it's not, strictly speaking, perceived to be a part of their job. This is because most GP practices were paid 95p per patient by the DoH during 06-07 to say they 'would' do it. It was an aspiration payment, however, and was not a binding 'will' do it contract. The budget for this payment was entitled working 'towards PBC' - not actually 'doing PBC - and actually there are very few people actively doing PBC today.
What is PBC from a GPs point of view? Simply put, it's about assessing local needs for healthcare, then designing and redesigning services to meet those needs. A key note is that PBC is not fund holding. Doctors do not get a 'pot of money' to spend as they see fit.
Dr Silver estimates that less than five per cent of GPs are even 'engaged' with the concept. Then there are the 'wilful non-engaged', who are steadfast in their decision to evade PBC, while there are also many 'unwitting non-engaged', GPs who simply don't know much about what is on the table. One reason why PBC has not been warmly received is because clinicians don't feel like they've been engaged in the process.
"Your average GP punter can't be bothered, and to have these discussions [regarding the minutiae of financing] take huge amounts of time. That's why they're not engaging."
Under PBC, GPs are asked to achieve the following in order to stretch the pound:
- Contain escalating costs and manage demand (obviously, ill patients requiring a hospital operation must get one, so doctors are encouraged to rationalise where they around the 'periphery')
- Reduce health inequalities (however, bringing too many private providers into the NHS may open this gap, as it has done in the US)
- Reduce outpatient referrals, particularly on electives (non-electives might require attention as currently many are handled by the out-of-hours service providers, which can lead to spokes in admissions depending who's answering the calls)
- Reduce follow-up appointments where possible (follow-ups, which can include simple tasks like letter-writing, can be hugely expensive and, under the current system, do not necessarily benefit the patient)
- Stop inter-consultant referrals (each 'first appointment' can generate a bill for £150.00)
- Reduce emergency admissions (however, only 25 per cent of admissions are initiated by GPs, with most being made by the out-of-hours service, many of which may be unnecessary).
Yet, while PCTs expect GPs to address all of these issues, "absolutely most importantly they want them to reduce prescribing spend", Dr Silver notes. A lot of targets are thrown at GPs regarding cutting prescribing spend, while each practice is compared with the 'performance' in this respect of its neighbours in an analysis document every three months. There is mounting pressure on GPs to reduce their drugs bill.
In order to gauge how PBC can work for groups of practices, some Strategic Health Authorities (SHA), such as South Central, are employing management consultants to assess the possibilities and devise a plan. Price Waterhouse Coopers are on an estimated £2m contract to examine how commissioning can (or not) be integrated across nine PCTs.
Some 'engaged' GPs have welcome this as it has not only pepped up the PCTs (relations between inquisitive GPs and PCT managers have been strained and unfruitful in some cases) but doctors feel they can argue productively with the impartial investigators as to the real worth of PBC and its prospects for success.
To date, commissioners have received three major strands of guidance on PBC. However, it has been possible to interpret each as slightly contradictory to the others. In order to even assess whether PBC could be a workable prospect for her, Dr Silver has employed a non-clinical manager to look after this part of her work.
Where does pharma fit in?
Dr Silver's honest view on this was that she wasn't specifically sure how pharma could best influence PBC to its benefit, "but it's going to be in partnering - which is about you providing the services as well, maybe with the GPs, maybe on your own".
Held on: 22/05/2007