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All awash

There is no going back, says James Johnson, chairman of the British Medical Association (BMA), of the momentous changes underway in the NHS

There is no going back, says James Johnson, chairman of the British Medical Association (BMA), of the momentous changes underway in the NHS. He's not wrong. Yet, while there can be no doubt that the changes are in full swing, so many questions about the shape of the future health service remain unanswered. How will a reduction in the number of Primary Care Trusts (PCTs) and the introduction of practice-based commissioning (PbC), payment by results (PbR) and private sector competition, affect the NHS, the pharmaceutical industry and their unique interaction? More importantly, will the changes benefit patients?

Confusion reigns as people attempt to unravel how best to move forward, while trying to unpick the measures brought in during the changes made just four years ago when PCTs were introduced.

News that the Department of Health (DoH) plans to halve PCT numbers, contract out community health services to private providers and reduce the number of Strategic Health Authorities (SHAs), as revealed in Commissioning a Patient-Led NHS, has left many practices wondering how the future will look.

The feeling of being all at sea is evident in many who feel that the DoH, while indicating that there will be universal coverage of PbC by the end of this year, in its document Practice-Based Commissioning: Achieving Universal Coverage, has not given enough advice on how this could be achieved.

However, the DoH is adamant that it has given detailed instructions on how PbC is to be achieved.

In January, we published the rules of 2006/07 and associated detailed documents covering PbC. Then, last month, we published Practice-based Commissioning: Early Wins and Top Tips for GPs and primary care staff on how to get involved with PbC, said David Hands, chief press officer, NHS at the DoH.

Health Secretary, Patricia Hewitt, said 2006 would be a year of transition, and she wasn't kidding. NHS instability will grow but, for New Labour, it's a small price to pay for competition, choice and increased efficiency.

~

The same, but different
Almost everyone you care to ask has a different perception of the new NHS and, while many have conflicting views, one thing is for certain: the NHS will operate differently in the near future.

PCTs that survive will expand their budgeting powers and influence, working under just nine SHAs, which may be absorbed into the DoH at a later date.

Four key changes will occur, the most important of which for the pharmaceutical industry is that commissioning and prescribing freedom will be given back to GPs. The difference from yester-year is that all of tomorrow's GPs may need to be private entrepreneurs.

Nurses and pharmacists will have greater prescribing rights in the changed system. PbR, whereby hospitals and health centres get paid for the number of patients they treat, will ensure that government money, via national tariffs, will follow patients. Finally, in an ideal world, if PbC works, GPs will be able to reduce hospital admissions, saving funds that can be reinvested into primary care.

In keeping with this utopian theme, the DoH wants PCTs to relinquish their role as the driving force behind local prescribing policy in all but the most serious or rare cases, such as HIV care, which are unprofitable or too sporadic for local facilities.

GPs or special health workers would become local experts in various fields. PCTs would pay for GP commissioning decisions, allowing money to follow patients to their place of treatment and, if necessary, pharmacists could make changes to prescriptions.

It all sounds very cosy, but it won't happen uniformly - PCT influence, PbC uptake, and multiple-prescriber levels will vary depending on locality, presenting us with an even more fragmented market, according to Angela McFarlane, managing director at HealthGain Solutions, an NHS liaison specialist.

Cart before the horse
The changes have received a mixed response. James Johnson has made the concerns of the BMA quite clear - a fear of government incompetence. The main problem with plurality of provision is a lack of a regulatory framework. Like many commentators, he believes the DoH started this process without writing the rules.

That said, both the BMA and the NHS Confederation feel that health workers could benefit by successfully grouping to form independent businesses, selling services to NHS and private firms.

Doctors' anger at a lack of methodology aside, there is a certain inevitability that GPs will adopt PbC - on this point at least Labour has learnt from the mistakes made by the Tories when they failed to enforce fundholding.

John Chater, editor of Binleys' NHS Guide, points out: GPs have been offered a great new contract that is more than any of them expected. In the initial phases of PbC they have also been guaranteed that their PCT will pick up the bill if they go over budget. They have the incentive of being allowed to keep any savings they make through self-budgeting too.

The NHS Alliance agrees. Its vision is one where small practices have a major role to play in the modern NHS by providing continuity in the doctor-patient relationship. GPs can provide a small, independent `nested' practice in one locale, or a `virtual super surgery' or `cluster', maximising the use of both small and large organisations.

For progressive doctors at least, commentators believe these changes herald opportunities.

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What about pharma?
The overriding feeling is one of confusion. The timetable is incredibly short. Last year PbC wasn't even on the agenda - now it must be done by December. Many practices don't even know what it is. For forward-thinking pharmaceutical companies, this is an opportunity to be there when things are being shaped, says independent consultant, Sue O'Donnell.

Today's climate offers the same opportunities as fundholding; then pharma companies were very keen to get involved and help GPs through the transition. However, PbC is different; it is likely to be `universal'. Pharma reps (many of whom are banging on locked doors at present) could offer GP clusters and other providers invaluable help - office space, technology and people skills. However, at this stage, help should be non-disease specific and unrelated to formularies.

While surgeries, PCTs and clusters develop their future relationships, being seen to provide support on a non-promotional basis would set any pharmaceutical company in good stead,
says O'Donnell.

Early start
While opportunities are there for the taking, it is still vital that pharma companies get in early. Pharma would be nuts if they weren't going into newly-formed clusters already, says Chater.

There's nothing to stop pharma being there to help, learn and influence the set up of new localities... the NHS is crying out for help. The old aversion to public-private partnerships is gone, gone, gone.

Dr Richard More, a practising GP and change-management consultant from Xytal, emphasises the importance of understanding this change. The days of persuading individuals to choose drug X over drug Y are coming to an end. Computer-based analysis will allow practices to know what they need and compare suitable market products. It will be winner takes all, he says.

Given that efficiency and cost-cutting will be the norm, it seems likely that new providers will start looking for solution-based firms. A brand that comes with trained nurses or other `add-ons' is much more likely to impress than a stand-alone drug. So far, Dr More says that the message has not got through to UK pharma strategy.

There is plenty pharma can do to prepare for the journey but it may have difficulty deciding which route to take.

While there is a strong argument for sales teams to continue courting PCTs, which still hold the majority of commissioning power, there is an increasingly strong case to suggest that PbC
will provide GPs with the most influence.

One thing is certain, a huge overhaul of your sales team is premature. This is not a time for knee-jerk reactions, says Mike Sobanja, director of Health Direction, a provider of NHS business intelligence. The NHS is a moving target - and his advice is to save your ammunition. Wait until the specifics of PCT restructuring come out before making wholesale changes.

HealthGain's McFarlane adds that, ultimately, it is the nature of any action that is core: The greatest danger in times of turbulence is not the turbulence itself... it is to act with yesterday's logic.

Yesterday's logic places PCTs at the top, as the vehicle to GPs. However, at a time when the powerbase is shifting in favour of doctors, it could be wise to rethink this approach.

Yesterday's logic was to jump into wholesale sales team reforms. Today's dictates that changing the industry before the rules are written is pointless. There is a period of flux to live through before the real shape of the NHS is unveiled. Health policy analyst, Ray Rowden, comments: Government plans will create a patchwork quilt of PCOs, where there will be locality-based commissioning in big PCTs, based around clusters of GP practices.

GP clusters and private providers will be given the right to compete for the local or specialised treatment of long-term and chronic illnesses. The pharma industry will, therefore, be faced with a far greater plurality of providers, Rowden notes.

The logical conclusion of this plurality is rather than try to sell to them all, pharma will one day join with a.n.other provider to bid to deal with one whole disease area, perhaps with a not-for-profit social entrepreneur, he continues.

~

Out of chaos comes order
Although some PCTs have devolved various powers to local practices, many GPs and PCTs are waiting until the DoH gives clearer guidance. So, pharma teams that pitch mainly at PCT level needn't panic - yet.

McFarlane describes the change as an evolution, not a revolution. PCTs will, therefore, continue to develop out-of-hospital opportunities, many with the pharmaceutical industry.

Yet, major change is around the corner. As John Chater points out: Before, pharma focused on identifying people at PCT level who had prescribing responsibilities, because commissioning budgets were sitting at PCT level. Now, PbC has thrown it in the other direction.

For Sue O'Donnell, who is in the process of introducing PbC to South Wandsworth's 22-practice GP cluster, the future is not yet written. There has been no real guidance on how to set up PbC... GP clusters don't even have the legal status to set up bank accounts, or employ people. Government guidance is urgently needed to resolve this.

Dr More agrees that GPs were expecting and willing a paper on `how to set up PbC'. Instead, they got a wishy-washy `PCTs and practices need to work together' document. As a result, many practices are in limbo, making it all the more worrying perhaps that some clusters have already begun commissioning.

O'Donnell has an interesting take on how clusters might affect pharma. We're making a formulary across the entire cluster, so sending sales reps to individual GPs seems pointless. Doctors can prescribe off formulary, but the reason for the cluster is to make these decisions and increase effectiveness.

The South Wandsworth cluster chooses a clinical and non-clinical director annually. It manages the set up of PbC and will, ultimately, contain the sort of people that pharma will need to identify and approach. O'Donnell is quick to point out, however, that democracy reigns. We can't make decisions on behalf of the cluster. We have a project board of one representative from each practice, which makes decisions.

For those pharma companies that still believe approaching individual GPs is the future, she has a stark warning. Most practices that aren't in a cluster really won't exist. They won't have enough money to deal with risk.

The author
Colin Jennings is staff writer on Pharmaceutical Marketing magazine

2nd September 2008

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