Nip and tuck

Sweeping NHS cuts and a budget deficit that's almost insurmountable: does the winter of discontent mean harder times for patients and pharma? The King's Fund's analysis shows that, by 2013-14, current spending plans will leave a £21bn gap between the most reliable estimates of NHS future funding needs and the money likely to be available to it. The one thing that hasn't changed under the new coalition is the drive for better value, quality and innovation started under Labour. If the terms Patient Reported Outcome Measures (PROM), 'commissioning of quality and innovation payments' CQUINs and value-based pricing (VBP) don't feature in your marketing plan, chances are that you have work to do. Porterhouse Medical is a specialist in providing guidance and collection tools in this area.

Market focus: citizen-centred NHS
The NHS is still criticised for not being consistently good at 'seeing the person in the patient' – could this also be a criticism of pharma? In a report published by the 2020 Public Service Trust, a move away from the traditional view of the patient to that of a citizen was recommended. A more 'citizen-centred NHS' can only be created using a performance framework that places value on improving user experience and delivering the outcomes that matter most to patients rather than focusing on processes. This is where PROMs fit in.

The societal move from patient to consumer to citizen

Conducting the PROMs
More than 100 years ago, Florence Nightingale suggested a health-related outcome measure for her patients: relieved, unrelieved and dead. Despite developments since then, attempts to measure the positive outcomes of healthcare have been slow and centred mainly on the question: "Does this intervention prevent or delay death?" An important step forward was made in April 2009, when the NHS became the first healthcare system to begin to collect PROMs routinely for four elective procedures.

Using a series of structured questions that ask patients about their health from their point of view, PROMs are intended to enable the patient perspective to inform decision-making in the NHS. The NHS Standard Contract makes it necessary for hospitals to provide PROMs for hips, knees, hernias and varicose veins operations. Highlighted in the consultation document on the future parameters of the NHS Outcomes Framework is the expansion of PROMs from elective procedures to chronic conditions. But current methodologies for acute care require questions to be asked of the patient before and after treatment, and so they can only be applied routinely to planned episodes of care.

Marketers need to ask themselves: 'Is my product used routinely in a planned episode of care?' If the answer is yes, then providing clinicians with a tool which will help them measure patient perceptions and outcomes while taking certain medications will help them fulfil the future requirements of the NHS Outcomes Framework and provide a robust business case for continued use of a product.

The sparkle of CQUINs
In a recent address to the British Society of Gastroenterology congress, Lord Darzi, a surgeon, said: "Measuring quality is nothing new to gastroenterologists, who have considerable experience of measuring quality in relation to outcomes, but it is also crucial to measure quality in relation to safety and patient experience indicators."

PROMs will provide a useful tool, in his view, along with the new system of rewarding quality through the CQUINs in driving quality improvements. The CQUIN payment framework makes a proportion of providers' income conditional on quality and innovation. He said that the tariff will be raised to six per cent in 2011 – at the Imperial College Healthcare NHS Trust, for example, this equates to around £38m.

What is the CQUIN payment framework?
The CQUIN payment framework is a national framework for locally agreed quality improvement schemes. It makes a proportion of provider income conditional on the achievement of agreed ambitious quality improvement goals and innovations. The CQUIN framework is intended to reward genuine ambition and stretch, encouraging a culture of continuous quality improvement in all providers.

To earn CQUIN cash, providers of acute, ambulance, community, mental health and learning disability services  must agree a full CQUIN scheme with their commissioners to include goals in the three domains: safety, effectiveness/patient experience and to reflect innovation. So PROMs and CQUINs are intrinsically linked: one is a way of providing a framework of standards aimed at improving patient outcome and experience; the other is a way of measuring it.

To marketers, the value in PROMS is how they can help clinicians secure additional funding either through the CQUINs framework (secondary care) or the NHS Outcomes Framework (primary care). Moreover, they provide marketers with a richer interaction with their customers and a better understanding of their customers' priorities – ultimately they will provide better evidence and help secure future funding for the use of their products.

Value-based Pricing (VBP)
Although it is argued that PROMs should supplement rather than replace existing measures of quality and performance, they are likely to become a key part of the way healthcare is funded, provided and managed. The new UK government plans to change radically the way medicines are paid for, introducing a value-based pricing system within the next four years.

The change to value-based pricing will not happen immediately – the current pharmaceutical price regulation scheme (PPRS) will first be allowed to run to 2014. A report by the Office of Fair Trading recommended reform, basing a drug's price according to the value the medicines provided. The National Institute for Health and Clinical Excellence (NICE) currently sets a cost-effectiveness threshold at £20-30K per quality life-year (QALY). What VBP aims to do is ask pharmaceutical companies to set the price range of the drug so that it falls within this or a future threshold.

In essence, NICE already does this by not recommending certain drugs for NHS funding. For example, in May 2010, NICE decided not to support sorafenib (Nexavar) for use in hepatocellular cancer in England and Wales, as it was not cost-effective; it costs around £27,000 (€32,400, $42,500) for each course of treatment and improves median survival by 2.8 months, generating an incremental cost per QALY for sorafenib versus best supportive care of £52,000.

How value-based pricing will be implemented is still in debate and the Association of the British Pharmaceutical Industry (ABPI) is currently working with the Department of Health to address this.

For the marketer, VBP may be a way off, but starting to think about the value his drug conveys as perceived by the patient (PROMs) and demonstrated through CQUIN and National Outcomes Framework is a paradigm shift in marketing and closely aligned to Government thinking.

Marketing plans that take account of PROMs, CQUIN, outcomes and the impact of VBP are ahead of the curve and will serve the firm and the individual well. So ask yourself the question 'Have I really finished my marketing plan yet?'

The Author
Jon Hallows is joint managing director of Porterhouse Medical Ltd
He can be contacted at jonhallows@porterhouse.biz or on +44 (0)118 913 9100.

To comment on this article, email editor@pmlive.com

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