Since the beginning of April this year, Clinical Commissioning Groups (CCGs) have become responsible for planning and buying healthcare services for patients in England. Replacing the existing Primary Care Trusts, the new 211 groups of GPs across the country are already liaising with local authorities and patient representatives to define priorities and decide how to spend their allocated budgets. How can pharma companies engage with clinical leaders in the new commissioning landscape?
Time for a change
The NHS is going through dramatic changes towards a clinically driven system that aims to empower doctors and patients and bring efficiencies, as outlined by the government’s Health and Social Care Act. The target is £20bn savings by 2015, about 4 per cent a year; an unprecedented cut in available funds.
The NHS National Commissioning Board, recently renamed as NHS England, was set up as an independent regulatory body to oversee the authorisation process for CCGs and to improve health outcomes for patients. It is an influential organisation, providing guidance to emerging CCGs and directly commissioning primary care and specialised services, such as particular cancers and most vascular care, for which it has a £12bn budget.
One of its key priorities for 2013 is the enforcement of generic prescribing. A study commissioned by the Board found the NHS could save £1bn a year if cheaper drugs were prescribed. It therefore recommended that GPs with expensive prescribing habits should be required to explain their decisions to their CCG – hence potentially creating conflicts between CCGs and pharmaceutical companies. Open Health Care UK and Mastodon C will develop software to help the new CCGs target local GPs whose prescribing practices are expensive.
The NHS Commissioning Board will work closely with the Department of Health, Care Quality Commission and the new patient advocate group, Healthwatch ,to support CCGs across England. The role of NICE has also been expanded to include social care, such as medicines management in care homes, which therefore allows it to remaining a pivotal organisation in the NHS.
Group structure
Last December, two thirds of CCGs were members of Clinical Commissioners, a partnership between the NHS Alliance, National Association of Primary Care and NHS Confederation, which hopes to become a collective authority and voice for commissioning leaders.
At an internal level, CCGs are divided into committees and sub-committees, so Prescribing or Medicines Review groups will be particularly influential on the drugs policy adopted, according to the different needs of their patient populations.
An important area will be patient referrals, as commissioning GPs will have to develop closer ties with consultants to achieve efficient patient care. Again, GPs are becoming more instrumental in the process and referral patterns are bound to change and vary from CCG to CCG.
CCGs are aided by Commissioning Support Units (CSU), local area teams and pharma will have to engage with them, as they will provide advice, business intelligence and support and clinical project management procurement, among other duties.
NHS cuts and doctors’ grievances
Trust is potentially the main hurdle to overcome when targeting the new decision makers in England. Access to GPs is becoming increasingly difficult as more doctors shun conventional pharma sales and so many companies and organisations are competing to grab GPs’ attention in a very crowded space.
The medical profession values the opinions of peers and of those in the NHS above all and has been known for its closed shop mentality. GPs are also becoming more aware of conflicts of interest, as their double role as commissioners and providers will be closely scrutinised. In this transitional phase with changes to the role of GPs and increase on demands, there is apprehension until a lasting relationship can be built.
Another issue is workload and lack of time to consume information or engage with patients, let alone other players, as many GPs are too hard-pressed to attend conferences, external meetings and digest heavy documents.
Some GPs fear the economic climate will make commissioning a ‘scapegoat’ for cuts in healthcare services. A GP in South Gloucestershire said she resents “being told to refer fewer patients, stop them from going to A&E and prescribe less drugs, taking the blame for the cuts. There’s less funding, but our work has increased by 50 per cent compared to 5 years ago.” Such is not a conducive environment for influencing commissioning GPs if the trend is towards more divisiveness and politicisation.
Michael Dixon, chairman of NHS Alliance and Clinical Commissioners’ interim president, said each CCG has to lead the way for the practices to go in the same direction as “many practices are hostile to changes because doctors are tired of meaningless reforms and angry about revalidation and pensions.”
Any successful engagement with clinical leaders has to take into account how current grievances can make GPs less open not only to commissioning but also to relationships with suppliers.
Positive engagement with pharma
A newly simplified system centred on clinical needs means that pharma can benefit greatly by aligning its own approach, providing value and an encompassing solution, which is less about the product and more about how it fits into the care pathway, how it improves patient outcomes and its role as part of the CCG’s strategic targets.
Dr Michael Dixon summed it up: “CCGs are more open to win/win solutions, and taking a long term view, focusing on outcomes, safety and quality, cost effectiveness, containing demand, risk sharing. A transparent relationship built on trust with partners will benefit all”.
Collaboration should be increased with GP-led organisations, such as Doctors.net.uk, as doctors rely heavily on colleagues and organisations run by and representing GP’s views.
Simon Grime, managing director for communications at Doctors.net.uk, said: “Pharma needs to listen and gather insight into how the Commissioning GPs will work and seek to understand the issues and new challenges that they face. These insights can then be used to create tailored engagement programmes for individual CCGs that can be measured and evaluated.
“All the data we’ve seen suggests that in order to gain insights and engage effectively, pharma needs to communicate with doctors through their preferred and trusted channels,” he said.
More research has to be carried out to study digital media habits of GPs and information format preferences. Little is available, apart from Manhattan Research’s Taking the Pulse Europe, which is an annual market research study focused on how doctors in the United Kingdom, France, Italy, Spain and Germany use the Internet, digital media, mobile devices and other technologies for professional purposes, pharma-communication and patient interaction.
Statistics show that while only about 14 per cent of doctors visit pharma websites once a month or more, over 3 million doctors worldwide use independent professional online networks – with the highest levels of engagement being in the UK.
The NHS is becoming a clinically driven system that aims to empower doctors and patients
“We have already run insightful research exercises to understand GPs’ communications preferences and information needs, including regional differences. Such online engagement offers a real opportunity to bridge the relationship between the sales force and doctors, whether they are a GP, hospital specialist or other prescriber,” explained Grime.
Tailored solutions at local level
Information and the training needs of commissioning GPs need to be better understood. Most clinical leaders are looking for best practice, evidence based commissioning, case studies, data comparisons across CCGs (including performance data), and scenario analysis.
An exhaustive database and profiling of CCGs and their key priorities, strategic planning, particularities and specific needs must be created to provide a full and detailed picture, so a tailored approach can be designed.
CCGs will have different needs but common grounds exist on government priorities such as care of the elderly, mental health management, long-term illness and increasing self-care.
Michael Sobanja, director of policy of NHS Alliance, said: “The best way to engage with CCGs is align your agenda with their agenda, know your customer, do your homework, understand variation, what makes people tick at the local level, finding which topical issues will drive the CCG.”
For instance, the Oxfordshire Clinical Commissioning Group, a pathfinder CCG that gained authorisation in December, has three strategic targets: “Decreasing inappropriate admissions, decreasing length of hospital stay, and reducing unnecessary follow-up appointments.”
Each locality will address the particular needs of its patch according to its clinical profile and there is a high degree of openness in obtaining data to support initiatives and services/products to achieve better outcomes. For instance, primary care prescribers will take a more prominent role in overseeing care pathway with an impact for pharma that presents challenges but also new opportunities.
