Wellard’s Healthcare Managers’ Forum King’s Fund, London 9 November 2004

1. Wellard’s Healthcare Managers’ Forum King’s Fund, London 9 November 2004 Where are we now with NHS liaison? Pre-reading slides for the discussion

2. Back in time...  The Tory internal market reforms and reorganisation of @ 1990 introduced new commercial imperatives: - FPCs to FHSAs > managed primary care - PAs and MAs > control of prescribing budgets  Glaxo Laboratories one of the first companies to respond by setting up a centrally run NHS Liaison Team  Glaxo criticised for moving too far, too fast  Through the 90’s many companies then followed

3. In came New Labour….  PCTs + PMS Pilots + LPS + SHAs  NSFs, NICE, CHI & Clinical Governance  Information for Health, EPRs, PRODIGY PCIPs, HIMPs, SaFFs, LTSAs  Nurse & pharmacist prescribing  NHS Direct, Walk-in Centres  NHS Plan, National Pharmacy Plans, StBOP  Modernisation Agency, NatPaCT

4. The explosion of change  Four UK National Health Services  Three HTA Agencies  DM is back!  A vast array of potential new customers  A vast array of potential new organisations  The Industry as a tobacco company….  Dry pipelines and ongoing mergers….

5. New selling paradigms  A new ‘family’ of roles has appeared to support ‘traditional’ SALES activity  Healthcare Liaison is now a key part of the MARKETING mix  Essentially a CORPORATE role with the need for both a corporate and disease area vision  Key output is quality of relationships built  Now an area of significant competitor activity  A rapidly developing field  Note the Takeda response

6. NHS customer wants In reality a complex mix of different needs operating at organisational, functional and personal levels  Assistance to meet Modernisation objectives - NSFs  Knowledge wants - of NHS changes, NHS networks, company, clinical & cost effectiveness  Contact with informed and empowered industry staff  Openness and honesty  ‘Soft’ monies  More educational materials and less freebies  Do customers also need to know more about how the Industry ‘works’?

7. NHS customer wants  55%of PCO Chief Executives said it was ‘fairly important’ for sales reps to have knowledge of NHS Modernisation and local implications - 55% as ‘very important’ for NHS Liaison Execs  40% felt this was either ‘marginally poor’ or ‘very poor’ for representatives.  50% of PCO Executives felt that knowledge of PCO’s priorities was ‘very poor’ for representatives and 50% ‘marginally poor’ for NHS Execs Pharmaceutical Marketing, April 2001

8. Some PCO quotes “They genuinely believe that you will want everything being offered and cannot see that you’re not interested in a lot that they have to offer.…they’ve got no idea what PCGs are about”. PCG Clinical Governance Lead “I don’t mean to be facetious but they come to see me so that I can educate them about how they should engage with us!”. Pharmaceutical Adviser “We really need people higher up or more senior for the PCG Board, maybe medically orientated or trained in pharmacy”. Clinical Governance Lead “They always start with huge flourishes and the tend to fizzle out a bit….”. PCO Chief Executive

9. Sales reps versus NHS Execs  Whilst 55%of PCO Board members are still seeing both medical reps and NHS Liaison staff, another 42% are only prepared to see NHS Execs  PCO Boards do not want reps ‘to be delivering joint working initiatives’ “I think reps serve a different function”. CG Lead “If I have queries I go to RBM level…they still have a promotional role but they tend to take a step up to a more strategic level”. Prescribing Adviser

10. Some Industry quotes “PCO plans are public… A rep therefore has no excuse if he/she turns up to see a member of a PCO without a good idea of what the priorities are” Adrian Adams, Novartis “ NHS Execs scored very poorly with PCO Chief Executives. This reflects how the Industry does not yet know how to talk to these people and what to offer them” Debbie Waterman, Watermark

11. A view from the NHS Alliance “ Healthcare development managers (HDMs) or NHS Liaison Managers, take your pick from the pseudonyms, all share the same goal - to develop relationships with PCTs. Not only do new skills need to be acquired for this new role, many old skills have to be unlearned so they don’t get in the way of the new ones…….some companies have, in my opinion, made the mistake of having the same person representing both sales and healthcare development….” Dr Graham Archard, Pharmaceutical Marketing

12. More customer feedback “The bigger companies seem to have the resources to help but some of the people in the field still seem to be very patronising, are bullish in their attitude and do not actually really understand what is going on in PCTs or indeed primary care.” Pharmaceutical Field

13. 3 propositions The Offering Corporate Therapy Area Regional Directors of Health & Social Care Product Regional Directors of Health & Social Care

14. HCM deployment 2004 Department of Health DH Lobbyist NICs 28 SHAs RHCM Local Health Economy @ 300 PCTs PCT HCM @ 400 Trusts GP Practices GPP HCM

15. Term III Blairite healthcare reforms  Patient Choice  NHS Foundation Trusts  Payment by Results  LTMC  Health of the Public  Commissioning  PCT & SHA changes  What will be the ‘so-what?’ to companies?

16. A company-wide impact?  Medical - NICE/SMC/AWMSG, disclosure, etc  Marketing - is the mix right? Reinvest to EBM?  GP Sales -are new skills, knowledge and competencies now required? e.g. account management (nGMS), and more “scientific based” detailing  Hospital Sales - do hospital business plans include a full environmental (NHS) analysis?  NHS Liaison - next steps?

17. Bottom line….  Keen understanding of NHS ‘value sets’ + language  Working ‘under cover’ and ‘going native’  One of the ‘Team’ - a desk at their place  Solution Selling - correct alignment  Partner, stakeholder or supplier?  Sleeping with the enemy - ABPI initiatives & PICTF  Expensive for the customer; cheap for company  The business imperative

18. Partnership Stakeholder Supplier Must contribute Can contribute No Contribution Respected Tolerated Generally ignored Acknowledged expertise May have expertise Expertise ignored At the table Listen to but may ignore Not involved Entitled to explanations No explanation Ignored Involved at development Involved later Not involved stage What kind of partnership?

19. NSFs & partnership “The Secretary of State is keen to involve the pharmaceutical industry in the development of NSFs…. Industry might wish to offer facilitation….The industry has both the expertise (and in some areas, resource capacity)...Collaborating with the industry in delivery of a NSF would be of significant advantage to both DoH and the Industry where a pharmaceutical intervention has been identified in the NSF…..”. Also see Meeting of Minds -www.NIMHE.org.uk New ABPI document

20. What is partnership? “....Partnership refers to situations where the organisations involved pool skills, experience and/or resources for the joint development and implementation of specific projects. Partner individuals or organisations have equal ownership of the project’s aims and strategy and there is a share commitment to its successful delivery....partnership differs from sponsorship, where an organisation will provide funds for a specific event or work programme.” Forming Productive Partnerships with Industry, UK Modernisation Agency, March 2004

21. Medicines & partnership “The pharmaceutical industry has the expertise on how and why medicines are used and it is important to work with them….keen to work in partnership with the industry both to support existing services and develop new services including the managed care of chronic conditions. Action: The SEHD will produce guidance on joint working between NHS Scotland and the Pharmaceutical Industry.” See The Right Medicine A Strategy for Pharmaceutical Care in Scotland(2002)

22. PCT & partnerships “The National Primary Care Trust Development Team is developing an organisational competency framework, which includes a ‘Partnership’ competency covering such areas as……working with the pharmaceutical industry.” See www.natpact.nhs.uk/home.php From National Service Frameworks : a practical aid to implementation in primary care. ‘Partnership Working’, DoH (2002)

23. DH Guidance Commercial Sponsorship - Ethical standards for the NHS (2000)  Recognition that partnerships with Industry may have benefits  Should be based on best clinical practice, value for money and be ethical and transparent  No linkage to purchase of particular products  Code of conduct given  Examples of potential conflict

24. Horses for courses  What is the ambition & vision?  Policy versus product (the brick wall)  Low, middle and high hanging fruit Walking the talk  Win-win v win-lose v lose-win v lose-lose  Adding value  Negotiating and navigating

25. Courses for horses  Janus - internal & external focus  PCO/Industry policies  Account Teams and NHS knowledge?  Keeping up to date with NHS changes  How to know what is going on when not around?  Rhetoric versus reality

26. Smart offerings  Products as ‘solutions’  Innovative initiatives that drive core sales  Initiatives/investments should create mutual and demonstrable benefit  Micromarketing?  Levels of ‘customer engagement’  Should drive the ‘Quality Agenda’  Need to be explicit with customers  OK to say no

27. A competency framework?  Commercial judgement - ROI and risk  Innovation - doing things differently Strategic thinking - thinking outside the box  Communication - up, down and across + language  Leadership - internal & external customers + team  Influencing - levers and relationships  Independence - understanding, empowerment, accountability and interdependence

28. Key development areas?  Clearer vision of the role Better internal understanding of the role  Greater dedicated marketing support  Key account competencies mandatory  ‘State of the Art’ NHS knowledge  Appropriate measurement measures

29. Moving forward “The Industry needs to properly understand all these changes and be reflective. There is a tremendous opportunity to develop new relationships now that everything is up in the air. The current set of changes that bring this instability provide an opportunity for some new thinking and it is probably important for industry to go through this new thinking.” Dame Gill Morgan

30. Some barriers  Entrenched anti-industry views  Lack of trust and suspicion of motives  Lack of understanding of private industry  Clash of value sets  New Cochrane policy

31. Some baggage! “There is a tendency for clinicians to treat the medical literature with too much respect….. opportunities for bias are enormous when sponsored by pharmaceutical companies…..particularly talks at scientific meetings….. authors are persuaded towards a greater emphasis on positive findings ….negative findings not reported .. many trials lack essential features of design to achieve an unbiased assessment of therapy.” “As I journeyed through the pharmaceutical jungle, I came to realise that, by comparison with reality, my story was as tame as a holiday postcard…researchers suffered vilification and persecution ...corporate greed.” The Constant Gardener, John le Carre

32. Factor Worst Case Best Case Govt. healthcare goals Component cost focus Overall outcomes focus Views on pharma Source of savings Valued contributor to industry health & UK Plc NHS balance of power Central Direction Local empowerment Clinical decision National ‘best practice’ Individual clinical making guidelines / formularies judgement Patient / Voter Accept rationing in Demanding improved quality expectations return for ‘free care’ of life, and willing to pay Views on private Hostile Supportive sector involvement Industry scenarios

33. Factor Old World New World Customer base Simple Complex Local control ‘Unmanaged’ Managed Primary Care Prescribing 1 Hospital-led PCT-led Prescribing 2 Non-evidence based Evidence based Central control No NICE, CHI, NSFs NICE guidance statutory S&M Traditional S&M More ‘sophisticated’ S&M Rep skill base ‘Simple’ More complex Market Access issues Unmanaged entry Managed entry Old World v New World

34. Key issues facing HCMs?  The role - now at a crossroads?  The clear vision - lobbying v detailing?  The vested interests - suspicion & jealousy?  No industry-wide standards - benchmarking  No cross-industry dialogue- Wellards HCM Forum  Other issues to discuss….

35. Wellards Health Care Managers’ Forum 2005