Beverly Barr, Vice-Chair and Market Access Lead, PM Society
Joining for discussion
Paul Midgley, Director of NHS Insights, NHiS Ltd; NHS Rushcliffe Clinical Commissioning Group, East Midlands Mental Health Commissioning Network
Panel discussion and debate
Industry is changing its promotional activity in response to NHS changes and more than half of the companies responding to a new survey by the PM Society have a function or person dedicated to NHS Partnerships or joint working. The research findings were presented for the first time by Dr Beverly Barr, Vice-Chair and Market Access Lead, PM Society as she set the scene at: Industry and the NHS – can promotion and partnership co-exist?, on Friday 31 January 2014.
96 member companies – 52 from industry and 44 service companies – responded to the PM Society survey carried out in December 2013. It asked questions in three key areas around promotional activities, NHS partnership and joint working and clinical commissioning groups (CCGs)/ Social care.
Nearly all the industry respondents (91.5%) had specific promotional activities aimed at payers and 83% were tailored to meet the needs of local payers. 55.6% of industry companies had a function or person dedicated to NHS Partnerships or joint working and more than half (53.8%) of industry respondents are currently working on a partnership/ joint working project (commonly five or more). 20.4% of agency respondents indicated they worked on such client projects (generally between two to four).
85% of industry and 56.8% of agency respondents considered NHS partnerships and joint working to be part of the commercial strategy. However, while industry believes it understands the difference between joint working, medical education, promotion and sponsorship, almost half the agency respondents have a ‘learning gap' around this.
Only a quarter of the industry respondents stated they have or are preparing a strategy to address the growing emphasis on social care and only 8.8% of agency respondents are currently working on or preparing for an industry sponsored project focused solely on social care.
All industry members believed that they had good knowledge about the relevant group/ NHS organisation that commissions the products they sell, but 23% of agencies did not believe that they are particularly knowledgeable about this.
Crucially, while a high proportion (87.5%) felt they have a good or better understanding of the needs of CCGs, more than half of them (59.5%) thought that their relationships with CCGs are neutral or poor.
"It seems that there is lots of knowledge but not the relationships with the groups or organisations who are particularly relevant for commissioning companies' products," concluded Dr Barr as she introduced the first speaker Di Vegh of the ABPI NHS Partnerships Team.
How to avoid divorce in your partnerships
Di Vegh, ABPI NHS Partnerships Team
Di Vegh has a great perspective on partnership working, having spent half her career working as an NHS commissioner and half in industry. She is now one of four regional ABPI NHS Partnerships leads, who map the same geography as NHS England. The teams' positioning is around industry as an integral part of the NHS's solution to the delivery of better patient outcomes and they are working to improve the environment and reduce barriers to access and uptake at a regional level. A key aspect of this is to support member companies in the development of joint working projects, although Di was keen to make it very clear that: "We are not the only way that the NHS can engage with pharma."
Joint working opportunities exist with many different organisations and the NHS Partnerships Teams, which are made up of senior representatives for ABPI member companies, have been stakeholder mapping and establishing an engagement plan for talking to leads. Access is sometimes easier, because the ABPI teams are not selling. Interestingly, most of the 30 or so joint working projects that Di's team are working on have come via AHSNs, which is where there seems the greatest appetite for this type of project. Focus points include the Formularies Good Practice Guide, NICE Implementation, medicines optimisation and knowledge exchange.
"The key to a successful joint working project is that an equal contribution is made by NHS and industry. This doesn't have to be money, it could be a resource," Di advised.
Di also talked through her top ten ‘don'ts' for joint working.
Ten 'Don'ts' in Joint Working
Don't just make it about your product. There are several thousand drugs in the BNF and medicines are about 10-15% of the budget. What about the service?
Narrow value propositions that are solely trying to respond to a change in the market, for example, competitor activity
Esoteric health economic arguments that take no account of PbR or basic NHS finance
Materials directed at the wrong segment: providers are fundamentally different from commissioners
Models that use data that is irrelevant, not used by the NHS or produce results at variance with NICE or those published in peer reviewed journals
Offers that the NHS already has, for example: NHS Change Model
Projects that are not sustainable
Projects that are disguised promotion
A cumbersome internal sign off process
Not including all the stakeholders
Executives' Sleepless Nights – Can Drugs Help?
Felicity Greene, Director of Operations NHS South CSU
A pharmacist by training, Felicity Greene brings a strong clinical perspective to her role at the NHS South CSU. "Working for the NHS you become accustomed to change and never having time to embed it, but what does pharma need to do to adapt?" she asked.
Like CCGs, CSUs are less than one year old. Their remit is to provide infrastructure support that CCGs can no longer fund individually, for example in HR, payroll and finance and contracting. "From January to March, next year's contracting is the only thing on everyone's mind, because if you don't get that right you won't have the right health economy for the following year," Felicity explained.
Transformational change and the joining up of health and social care will be at the heart of future success. "Preventing patients from becoming acute and getting them home with appropriate support sooner presents a great opportunity for industry who can support this change," Felicity explained. She cited the Isle of Wight as the first region in the UK to have one board that manages acute, community and ambulance services so that they can be flexible.
"Ignore at your peril the local authorities who are coterminous to the CCG and acute trusts," Felicity warned. Health and wellbeing boards are growing in in power with the move towards transformational change. Familiarising yourself with the Better Care Fund
is a good starting point for understanding this better.
The other key area for CSUs is communications and public/ patient involvement and involving certain population groups can be challenging. In a significant change, Trust board meetings are all now public with the papers available online. Felicity commented: "Public records are a key opportunity for industry to be able to understand more about a region and how it might engage with the NHS there." Transformational change is also important because it underpins most of what the NHS is aiming to achieve. Some – not all – CSUs are also playing a clinical support role in independent funding requests, medicines optimisation and continuing healthcare.
What keeps CSU executives awake at night?
Quality – it is improving but with the media focus on negatives, the pressure is on to get even better and within tight financial constraints
Responding to local needs: primary care trusts worked on a population basis, CCGs are sub population. How can providers who are desperately trying to maintain income be managed in the context of ensuring that patients are getting the service that they want? CCGs are so much smaller that they may not have the power that they once had with the acute trusts unless they work together
The Better Care Fund – it will totally change the landscape, with a significant transfer of money from health into social care. It makes the patient pathway, prevention and post-acute care critical and there is a huge opportunity for pharma to help support the system through this transformational change.
"Further, industry needs to work to ensure that it plays an appropriate role. If an NHS manager cuts staff they will be demonised on the front page of the local press. Cut a drug budget and you are a hero. Pharma needs to be seen as part of the financial solution rather than a problem, despite the relatively low proportion of spend on medicines – it's an easy target," she explained. The big management consultancies are all already in on pathway design and pharma also has the intellectual firepower to help with this. Importantly, there are opportunities to make use of industry's global experience.For example – allow the executives to self-fund, but facilitate a meeting between the NHS, which must be paperless by 2018, and Spanish executives in Madrid who have already gone paperless.
Importantly, innovation doesn't need to be brand new – take good practice from one region and help to embed it elsewhere. The NHS is still in flux and acute providers are still trying to work out how this will impact on them.
"True partnership working needs to kick up a notch while the NHS is very receptive," Felicity concluded. "Industry could do a huge amount to move things forward."
Marketing, advertising, selling and the customer
Jonathan Dancer, managing director, Redbow Consulting Group
Promotion and partnership can co-exist, Jonathan Dancer argued. In fact, potential benefits include improved concordance, patient education and lifestyle applications, support for treatment initiation, outcomes measurement, service design and medical education. However there is a need to overcome potential barriers to partnership working. Misperceptions, stereotyping or one bad experience can destroy trust and sometimes practical issues get in the way. The promotion must be aligned with the needs of the customer and cannot be gratuitous. Importantly, there is no real life data to correlate promotional investment with sales. Rather the predictability of returns on promotion is based on the type and level of promotion, the extent of an unmet need, familiarity with technology and ease of market access. The key lies in the Kotler definition of marketing (2002) as a process through which individuals/ groups obtain what they need and want through creating and exchanging products and value with each other. "Value must be the watchword. It doesn't exist until it is perceived by the customer and the customer must experience the ‘product' to perceive value. Adoption involves establishing relevance to their own life/ role," explained Jonathan.
To illustrate how value is in the eye of the beholder, Jonathan showed various works of art, one by a toddler of infinite value to her mother and another similar by artist Franz Kline which recently sold for millions.
"We know that industry and the NHS needs to collaborate and communicate and marketing and market access are increasingly convergent. Trust, partnership, promotion and relationship all centre around creation and the exchange of value, with value the universal currency that can enable promotion and partnership to co-exist," Jonathan concluded.
Discussion and debate initially centered around barriers and challenges. "Trepidation and fear often prevent innovation and partnership working and clients frequently think it's easier just to do MEGs," said one contributor. Di Vegh was quick to respond: "Often when I have trouble with companies it is because there is no internal process or standard operating procedures. There are standard contracts now available online and I can also go in and spend a day with medical and legal to show how to map the process. It's free and it's an ABPI member benefit, but there must be the appetite in the company," Di added.
Jonathan Dancer highlighted how payer and market access spend is increasingly convergent, but warned that payers dislike that particular label because they are often strongly clinically orientated. Felicity Greene confirmed that 3 out of 5 on the NHS South CSU Board are clinicians and warned: "It is difficult to split the two." The term commissioner or commissioning organisation is more appropriate.
There was a question for Felicity about why CCGs don't feel that they have the power to take on the acute trusts. She responded: "Competition is a new thing, but importantly they want to keep the health economy stable and so they will only really use ‘any qualified provider' when the Trust can't provide a service or it's really not right. Where it is working best is where all those CCGs feeding into one acute provider have joint requirements and can work together to get the best results for the local population. Any ‘rocking of the boat' will need to be in the context of transformational change and not as a knee-jerk reaction."
Paul Midgley confirmed that commissioning locally in his area is organised so that the CCGs work together with a lead commissioner from a single CCG for different parts of the contract.
Felicity added that data is key and one of her roles is to ensure it is accurate. "It's a real challenge and we need to improve. You won't get true integration until everyone can access the right data for the right reason," she explained. Di commented that she recently met with HSIC and NHS England to see how to advise companies on this. "70% need to sign up to make the data work and so the official guidance is to watch and wait on uptake," she commented.
The question of industry access was raised. "It is a question of the right people talking to the right people," answered Felicity. "For a strategic offer you need to be talking to a director, but you'll need a senior person from the company in on that meeting who is well briefed in the local need. The lower down the CCG the more the person is focused on getting through that day and that month. Ideally industry needs to be offering high level strategic solutions that can add real value and are delivered by the right senior person. It is also about showing the value-add and stepping back from the product and being independent from your sales force," she explained. "If you get some good wins with a CCG you will be surprised how quickly the word gets around!"
“The industry has a huge responsibility but there are opportunities for us all to take on as we move forward.”
Paul highlighted that the strategic plans are being refreshed in April for the period to 2018 and warned: "If you don't understand what they are trying to do in your disease area, you don't stand a chance. Read the Board papers, go to the meetings – these are all ways of identifying opportunities. Tailor your approach according to the person you are speaking to and if you hit a brick wall in one direction – say medicines management – then try service pathways! Health and Wellbeing Boards, Academic Health Science Networks (AHSNs) and Healthwatch also have much under-tapped potential," Paul concluded.
In the concluding comments, the panel agreed that promotion and partnership can co-exist, but with caveats. It is incumbent on industry to make sure that they build trust by finding alignment and mutual value. Communicating that to the NHS is a challenge, but it is important also that industry is honest and open about what is in it for them and the approach must be locally-driven not based on an agenda drawn up in head office.
Beverly Barr observed as she closed: "The industry has a huge responsibility but there are opportunities for us all to take on as we move forward."